Form Il-1363 - Application For Cercuit Breaker And Prescription Coverage

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

27 Count the total number of persons you are reporting from Lines 2 and 10, and

if you are reporting qualified additional residents (see instructions), you must

include the number from Schedule B, Line 16. Write the total in the box ........... 27

If “YES,” go to Step 5.

Did you write

in Box 27 and is Line 25 less than

$21,218?

Did you write

in Box 27 and is Line 25 less than

$28,480?

If “NO,”

. See Step 4 instructions,

“Projecting your income.”

Did you write

(or more) in Box 27 and is Line 25 less than

$35,740?

Step 5: Tell us about the Illinois property tax or rent you paid in 2002.

28 Property tax you paid in 2002

. ............................................... 28

(both installments)

29 Mobile home tax you paid in 2002

. ................................................. 29

(yearly total)

30 Rent you paid in 2002

Does your rent include food? yes

(yearly total).

To whom did you pay rent in 2002?

Name __________________________________________ Phone (__ __ __) __ __ __ - __ __ __ __

Address ________________________________________ City______________________State_____ZIP________

How many months did you rent here in 2002?

______________

If you had more than one landlord, attach a sheet with the information requested on Lines 30a and 30b

above for each one.

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.

31 Nursing, retirement, or shelter care home charges you paid in 2002

... 31

(yearly total)

To whom did you pay nursing, retirement, or shelter care home charges in 2002?

Name __________________________________________ Phone (__ __ __) __ __ __ - __ __ __ __

Address ________________________________________ City______________________State_____ZIP________

How many months did you live here in 2002?

______________

If you lived in more than one nursing, retirement, or shelter care home, attach a sheet with the

information requested on Lines 31a and 31b above for each one.

Do not include any amounts paid by Human Services.

Step 6: 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. I also 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

Pharmaceutical Assistance program or SeniorCare. I also agree that if I receive any such payments or other payments or benefits under these programs 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.

32 _____________________________/___/___

34 ________________________(____)________

Claimant’s signature

Date

Preparer’s name (Please print or type.)

Phone number

33 _____________________________/___/___

Do not send us any checks or money

Spouse’s signature (If living together)

Date

with your application.

If you need additional assistance

• visit our Web site at

• call us at 1 800 624-2459, or

• call our TDD (telecommunications device for

the deaf) at 1 800 544-5304

If applying for prescription coverage or the

If ONLY applying for a grant or license plate discount

SeniorCare rebate

ILLINOIS DEPT OF REVENUE/PHARMACEUTICAL

ILLINOIS DEPT OF REVENUE/CIRCUIT BREAKER

PO BOX 19022

PO BOX 19003

SPRINGFIELD IL 62794-9022

SPRINGFIELD IL 62794-9003

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 prescription coverage. This form has been approved by the Forms Management Center.

IL-492-2740

IL-1363 back (R-12/02)