Form Il-1363 - Application For Circuit Breaker And Illinois Cares - 2007

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State of Illinois
Rod R. Blagojevich, Governor
Illinois Department on Aging
2007 IL-1363
Application for Circuit Breaker and
Official use only
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
City
______________________
State
____
ZIP
___________
3 Married, but not living together
4
8
Phone
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Are you
Male
Female
Area code
5
Yes, I want help paying for my drugs or a monthly rebate.
See instructions for more information.
Step 2: Tell us about your spouse (husband or wife).
Complete this step if you checked Marital status 2.
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
Yes, I want help paying for drugs for my spouse or a monthly rebate.
See instructions for more information.
Step 3: Write only the claimant’s and spouse’s total income for 2007.
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) .........................
20
20
$0.00
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.
25 Add Lines 13 through 24. This is your total income.
25
$0.00
Do not include Lines 17a and 18a in your total.
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.
b
Postmark deadline for filing is December 31, 2008.
IL-1363 1 of 4 (R-12/07)
Go to Page 2

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