Form Il-1363 - Application For Circuit Breaker / Illinois Cares Rx / License Plate Discount - 2008 Page 4
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3
4H
:
SECTION
For your or your spouse’s Illinois Cares Rx benefits or monthly rebate.
If you or your spouse want help paying for drugs or a monthly rebate, failure to complete this section will delay
the processing of your application.
36
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
no
If “yes,”
a Single: Is the total value of the items listed above worth more than $12,510? yes
no
b Married and living together: Is the total value of the items listed above worth more than $25,010? yes
no
If you answered “no” on Line 36, Line 36a or 36b, you must complete Schedule C.
I
:
SECTION
For the People with Disabilities Ride Free Transit Card.
See instructions.
Complete this section only if you or your spouse want to apply for the People with Disabilities Ride Free Transit Card.
37
Yes, I want to apply for the Transit Card.
38
Yes, my spouse wants to apply for the Transit Card.
J
:
SECTION
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, by, and between 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; (3) citizenship and identification information maintained by the
Illinois Secretary of State; and (4) identification information for ride programs offered by mass transit authorities, 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.
X
39
41
______________________________ ___/___/___
___________________________ _____________
Claimant’s signature
Date
Preparer’s name (Please print or type.)
Phone number
Official use only
X
40
______________________________ ___/___/___
_
Spouse’s signature (If living together)
Date
Go to Page 5 - Schedule C
SHAP
County/Sub-Area Code
Postmark
If applying for ALL Form IL-1363 benefits,
If ONLY applying for a grant, license plate
including Illinois Cares Rx, mail to:
discount and/or the free ride, mail to:
deadline for filing
CIRCUIT BREAKER/ILLINOIS CARES RX
CIRCUIT BREAKER
is Dec. 31, 2009.
ILLINOIS DEPARTMENT ON AGING
ILLINOIS DEPARTMENT ON AGING
P.O. BOX 19022
P.O. BOX 19003
SPRINGFIELD, IL 62794-9022
SPRINGFIELD, IL 62794-9003
If you need assistance,
1) visit on the Internet, 2) find a local agency serving seniors by calling
the Senior HelpLine at 1-800-252-8966, or 3) call us at 1-800-624-2459 or 1-888-206-1327 (TTY).
This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act.
IOCI 0014-09
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-12/08)
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