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

Step 8: For your or your spouse’s prescription drug benefits or monthly rebate.

Complete the following information only if you or your spouse are eligible for Medicare for hospital or doctor expenses.

Do you, your spouse (if married and living together), or both of you own any of the following items:

- Bank accounts (checking, savings and certificates of deposit);

- Stocks, bonds, savings bonds, mutual funds, individual retirement accounts and similar investments;

- Real estate (other than your home); or

- Any other cash at home or elsewhere?

yes

If yes,

a Single: Is the total value of the items listed above worth more than $11,990? yes

b Married and living together: Is the total value of the items listed above worth more than $23,970?

yes

If you answered “no” on Line 38, Line 38a or 38b, you must complete Schedule C.

Step 9: Sign below.

Under penalties of perjury, I state that I have examined this form and, to the best of my knowledge, it is true, correct, and complete.

I give the state of Illinois permission to get records from anyone concerning information on this form. As permitted by law, and

subject to revocation, I authorize disclosure of the following information to the Illinois Department on Aging and the Illinois Department

of Healthcare and Family Services for the Circuit Breaker/Illinois Cares Rx Programs: (1) citizenship, identification, and HIV/AIDS

status information maintained by the Illinois Department of Public Health; (2) tax return information maintained by the Illinois

Department of Revenue; and (3) citizenship and identification information maintained by the Illinois Secretary of State, for the

limited purposes of confirming my eligibility for applicable benefits and related outreach enrollment efforts through the end of the

appropriate audit period. If resource availability permits, I also authorize the state of Illinois to apply on my behalf for any federal

drug benefits I may be eligible to receive under the Medicare program. I assign to the state of Illinois my right to any benefits,

including reimbursement, under any private plan of assistance, public assistance program, insurance plan, or from any liable third

party, for prescription drugs that I receive through the Illinois Cares Rx program. I also agree that if I receive any such payments

or other payments or benefits under the programs on this form in error, or that I was not entitled to, I will repay them to the state of

Illinois. I authorize release of medical and pharmaceutical records for audit and verification purposes, and exchange of health care

information between any drug utilization review service authorized by the state of Illinois and any of my physicians and pharmacists

to the extent necessary for the operation of a drug utilization review service.

______________________________ ___/___/___

___________________________ _____________

Claimant’s signature

Date

Preparer’s name (Please print or type.)

Phone number

______________________________ ___/___/___

Official use only

Spouse’s signature (If living together)

Date

SHAP

County/Sub-Area Code

If you need additional assistance

Go to Page 5 - Schedule C

• visit

on the Internet

1-800-252-8966

• to find a local agency serving seniors, call the Senior HelpLine at

1-800-624-2459

1-888-206-1327 (TTY)

• call us at

If applying for ALL Form IL-1363 benefits —

including Illinois Cares Rx

If ONLY applying for a grant and/or license plate discount

CIRCUIT BREAKER/ILLINOIS CARES RX

CIRCUIT BREAKER

ILLINOIS DEPARTMENT ON AGING

PO BOX 19022

PO BOX 19003

SPRINGFIELD IL 62794-9022

SPRINGFIELD IL 62794-9003

Postmark deadline for filing is December 31, 2008.

This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act.

Disclosure of this information is REQUIRED. Failure to provide information could delay your grant and/or prescription coverage. IL-402-1093

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

Form Il-1363 - Application For Circuit Breaker And Illinois Cares - 2007 Page 4

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