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

Step 4: Does your total income allow you to file this application?

Write household size (add the number of persons on Lines 2 and 10, and on Schedule B, Line 9). .....

See instructions for more information.

Step 5: Tell us about the Illinois property tax or rent you paid in 2007.

Property tax you paid or was payable in 2007

. .....................

(total of both installments)

Mobile home tax you paid in 2007

. .............................................................

(yearly total)

Rent you paid in 2007

Does your rent include food? yes

(yearly total).

a To whom did you pay rent in 2007?

Name

_____________________________________________

Phone

( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

Address

_____________________________________

City

____________________

State

____

ZIP

____________

b How many months did you rent here in 2007?

b______________

Attach page if other rentals.

Do not include amounts paid by a Section 8 program.

If you now live in public housing, but last year lived in private housing, see the instructions for Line 30.

Nursing, retirement, or shelter care home charges you paid in 2007

. ............

(yearly total)

a To whom did you pay nursing, retirement, or shelter care home charges in 2007?

Name

_____________________________________________

Phone

( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

Address

_____________________________________

City

____________________

State

____

ZIP

____________

b How many months did you live here in 2007?

b______________

Attach page if other charges.

Do not include amounts paid by Human Services.

Step 6: For your prescription drug benefits or monthly rebate.

See instructions for more information.

Are you a

U.S. citizen or

qualified noncitizen?

You may still get some drug coverage, a grant, and a license plate discount even if no box is checked above.

Are you eligible for Medicare Part A and/or Part B for your hospital or doctor expenses? yes

If “no,” go to Line 34.

a If you are already enrolled in a Medicare Part D plan, what is the name of your plan?

AARP Medicare Rx Preferred

Health Alliance Medical Plans

SilverScript

Essence

HealthSpring

UnitedHealth Rx Basic

Erickson

Humana

WellCare

Evercare

OSF HealthPlans

Other: __________________

First Health Part D – Premier

PersonalCare

Group Health Plan (GHP)

SecureHorizons by United Healthcare

b Have you applied with Social Security for “extra help” under Medicare Part D? yes

See instructions for added "wrap around" benefits.

c Do you have HIV/AIDS? yes

d Print the name and claim number as it appears on your Medicare card or Railroad Retirement card.

________________________________________________

First name

Last name

Claim number

IL-1363 2 of 4 (R-12/07)

Go to Page 3

Form Il-1363 - Application For Circuit Breaker And Illinois Cares - 2007 Page 2

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