Form Il-1363 - Application For Circuit Breaker / Illinois Cares Rx / License Plate Discount - 2008 Page 2
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1
2
3
4D
:
SECTION
Does your total income allow you to file this application?
See instructions.
25
25
Write household size (add the number of persons on Lines 2 and 9, and on Schedule B, Line 9). .......
E
:
SECTION
Tell us about the Illinois property tax or rent you paid in 2008.
26
26
Property tax you paid or was payable in 2008 (total of both installments). .................
27
27
Mobile home tax you paid in 2008 (yearly total). ...........................................................
28
28
Rent you paid in 2008 (yearly total). Does your rent include food? yes
no
a To whom did you pay rent in 2008?
Name
_____________________________________________
Phone
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Address
_____________________________________
City
____________________
State
____
ZIP
____________
b How many months did you rent here in 2008?
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 28.
29
29
Nursing, retirement, or shelter care home charges you paid in 2008 (yearly total). ...........
a To whom did you pay nursing, retirement, or shelter care home charges in 2008?
Name
_____________________________________________
Phone
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Address
_____________________________________
City
____________________
State
____
ZIP
____________
b How many months did you live here in 2008?
b______________
Attach page if other charges.
Do not include amounts paid by Human Services.
Sections F, G and H should only be filled out if you are requesting Illinois Cares Rx benefits
or the monthly rebate. (If “no,” go to Section I.)
F
:
SECTION
For your Illinois Cares Rx benefits or monthly rebate.
See instructions.
30
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.
31
Are you currently eligible for Medicare Part A and/or Part B for your hospital or doctor expenses? yes
no
(If “no,” go to Line 32.)
a If “yes,” print the name and claim number as it appears on your red, white and blue Medicare card or
Railroad Retirement card.
________________________________________________
First name
Last name
Claim number
b If you are already enrolled in a Medicare Part D plan, what is the name of your plan?
AARP Medicare Rx Preferred
Group Health Plan (GHP)
SecureHorizons
1
6
11
by United Healthcare
Essence
Health Alliance
2
7
Medical Plans
Erickson
SilverScript
3
12
Evercare
HealthSpring
UnitedHealth Rx Basic
4
8
13
First Health Part D
Humana
WellCare Classic
5
9
14
— Premier
PersonalCare
Other: __________________
10
15
c Do you have HIV/AIDS? yes
no
See instructions for added "wrap around" benefits.
IL-1363 2 of 4 (R-12/08)
Go to Page 3
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