Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, Ride Free Transit Card, Illinois Cares Rx - 2011
Download a blank fillable Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, Ride Free Transit Card, Illinois Cares Rx - 2011 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, Ride Free Transit Card, Illinois Cares Rx - 2011 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Use your 'Mouse' or the 'Tab' key to move through the fields, use your 'Mouse' or 'Space Bar' to enable the "Check Boxes".
Application for
State of Illinois
Illinois Department on Aging
• Circuit Breaker Grant
• Illinois Cares Rx
• License Plate Discount
2011 IL-1363
• Ride Free Transit card
Official use only
A
section
:
Tell us about yourself (claimant).
Please print.
5
1
Social Security number
Birth date
Month
Day
Year
2
6
only one box)
Name
___________________________________________
Marital status (
First
MI
Last
1 Single, widow(er), or divorced
3
Address
_______________________________
Apt.
______
2 Married/civil union and living together
City
______________________
State
____
ZIP
__________
3 Married/civil union, but not living together
4
7
Phone
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Are you
Male
Female
Area Code
B
Tell us about your spouse.
section
:
Spouse includes parties to a civil union.
Complete this section if you checked Marital status 2.
8
8
Your spouse’s Social Security number. ..............
________________________________________________
9
9
Your spouse’s name. ..........................................
First
MI
Last
10
10
Your spouse’s birth date. .................................
Month
Day
Year
c
section
:
Claimant’s and spouse’s total income for 2011.
(See instructions)
You must include your spouse’s income (if married and living together).
Social Security, SSI benefits. Include Medicare deductions (yearly total) .....................
11
11
12
12
Railroad Retirement benefits. Include Medicare deductions (yearly total) .....................
Civil Service benefits (yearly total) .................................................................................
13
13
14
14
Annuity benefits (yearly total) .........................................................................................
15
15
Other pensions (yearly total) .................. a nontaxable
...... b taxable
16
16
Veteran’s benefits (yearly total) .............. a nontaxable
..... b taxable
17
17
Human Services and other cash public assistance benefits (yearly total) .....................
$0.00
Wages, salaries, and tips from work (yearly total)
18
18
+
=
Claimant
Spouse
Interest and dividends received (yearly total) ................................................................
19
19
20
20
Net farm, business or rental income or (loss). If loss, attach copy of U.S. 1040. .........
21
21
Net capital gain or (loss). If loss, attach copy of U.S. 1040 and Schedule D. .............
22
22
Other income, (loss) or (deductions). If loss or deductions, attach copy of U.S. 1040. .
23
This is your total income.
23
$0.00
Add Lines 11 through 22.
Do not include Lines 15a and 16a in your total.
Postmark deadline for filing is December 31, 2012.
IL-1363 1 of 4 (R-12/11)
Go to page 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, Ride Free Transit Card, Illinois Cares Rx - 2010
Legal
Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, And Optional Help Paying For Drugs (pharmaceutical Assistance Or Seniorcare) - 2004
Financial
Form Il-1363 - Application For Circuit Breaker / Illinois Cares Rx / License Plate Discount - 2008
Legal
Related Categories
Parent category: Medical