Form Il-1363-X - Amended Application For Form Il-1363 Benefits - 2007
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Illinois Department on Aging
20_ _ IL-1363-X
Amended Application for Form IL-1363 Benefits
Official use only
You should file Form IL-1363-X if you need to correct any errors made on your original Form IL-1363,
Application for Circuit Breaker and Illinois Cares Rx.
Step 1: Tell us about yourself (claimant).
Please print.
1
6
Social Security number
Birth date
Month
Day
Year
2
7
Name
____________________________________________
Marital status (
only one box)
First
MI Last
1 Single, widow(er), or divorced
3
Address
_______________________________
Apt.
_______
2 Married and living together
3 Married, but not living together
City
______________________
State
____
ZIP
___________
4
8
Phone
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Are you
Male
Female
Area code
5
You cannot apply for drug coverage on this form (see instructions).
Step 2: Tell us about your spouse (husband or wife).
If none or deceased, go to Step 3.
9
9
Write your spouse’s Social Security number. ....
10
10
Print your spouse’s name. ...............................
_______________________________________________
First
MI
Last
11
11
Write your spouse’s birth date. ........................
Month
Day
Year
12
Your spouse cannot apply for drug coverage on this form (see instructions).
Step 3: Tell us your total income for the year for which you are filing this amended
application
.
(include both claimant and spouse if living together)
Correct income or losses
13
13
Social Security, SSI benefits. Include Medicare deductions (yearly total) ....................
14
14
Railroad Retirement benefits. Include Medicare deductions (yearly total) ....................
15
15
Civil Service benefits (yearly total) ................................................................................
16
16
Annuity benefits (yearly total)........................................................................................
17
17
Other pensions (yearly total) ................. a nontaxable
..... b taxable
18
18
Veterans’ benefits (yearly total) ............. a nontaxable
..... b taxable
19
19
Human Services and other cash public assistance benefits (yearly total) ....................
$0.00
20
20
Wages, salaries, and tips from work (yearly total)
=
+
Claimant
Spouse
21
21 Interest and dividends received (yearly total) ...............................................................
22
22
Net farm, business or rental income or (loss). If loss, attach copy of U.S. 1040. ........
23
23
Net capital gain or (loss). If loss, attach copy of U.S. 1040 and Schedule D. ............
24
24
Other income, (loss) or (deductions). If loss or deductions, attach copy of U.S. 1040.
$0.00
25
25
Add Lines 13 through 24. This is your total income. ...................................................
26
If you rented out any part of your home to someone else, complete Lines 26a and 26b.
_____________
a Write the number of rooms in your home.
a
_____________
b Write the number of rooms you rented to someone else.
Go to Step 4
b
Schedule X / IL-1363 (R-12/07)
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