Form Il-1363 - Application For Circuit Breaker And Pharmaceutical Assistance

Illinois Department of Revenue

Application for Circuit Breaker

2000 IL-1363

and Pharmaceutical Assistance

Postmark deadline for filing is December 31, 2001.

Official use only

Step 1: Tell us about yourself (claimant).

Please print.

6 Birth date

__ __/__ __/__ __ __ __

1 Social Security number

Month

Day

Year

2 Name______________________________________________

7 Marital status

(

only one box.)

First

Last

Single, widow(er), or divorced

3 Address_________________________________ Apt._______

Married and living together

City_______________________ State_____ ZIP

______________

Married, but not living together

4 Phone (__ __ __) __ __ __ - __ __ __ __

• If you are a first-time filer, you must

Area code

attach proof of age. See instructions.

Check “Yes” if you are applying for

• If you are disabled, see instructions

Pharmaceutical Assistance coverage. Yes

for what you may need to attach.

Step 2: Tell us about your spouse (husband or wife).

If none or deceased, go to Step 3.

8 Write your spouse’s Social Security number. ..8

9 Write your spouse’s name. .............................. 9 __________________________________________

First

Last

10 Write your spouse’s birth date. ..................... 10 __ __/__ __/__ __ __ __

Month

Day

Year

Check “Yes” if your spouse is applying for

• If applying for Pharmaceutical Assistance coverage,

see instructions for what you may need to attach.

Pharmaceutical Assistance coverage. Yes

Step 3: Write only the claimant’s and spouse’s total income for 2000.

12 Social Security, SSI benefits. Include Medicare deductions

. ............ 12

(yearly total)

13 Railroad Retirement benefits. Include Medicare deductions

. ........... 13

(yearly total)

14 Civil Service benefits

. ...................................................................... 14

(yearly total)

15 Other pensions and annuity benefits

. .............................................. 15

(yearly total)

16 Veterans’ benefits

. ............................................................................ 16

(yearly total)

17 Human Services and other cash public assistance benefits

. ............. 17

(yearly total)

18 Wages, salaries, and tips from work

.____________+___________= 18

(yearly total)

Claimant

Spouse

19 Interest and dividends received

. ...................................................... 19

(yearly total)

20 Net rental, farm, and business income or (loss).

. ......... 20

If loss, attach copy of U.S. 1040

a Write the number of rooms in your home.

a _____________

b Write the number of rooms you rented to someone else. b _____________

21 Net capital gain or (loss).

. ....................................... 21

If loss, attach copy of U.S. 1040

22 Other income or (loss)

. .......................................... 22

. If loss, attach copy of U.S. 1040

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

23 Add Lines 12 through 22. This is your total income.

24 Count the total number of persons you are reporting from Lines 2 and 9, and

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

include the number from Schedule B, Line 41. Write the total in the box ........... 24

Did you write

in Box 24 and is Line 23 less than

$21,218?

If “YES,” go to Step 5 on the next page.

Did you write

in Box 24 and is Line 23 less than

$28,480?

If “NO,”

. You do not qualify.

Did you write

(or more) in Box 24 and is Line 23 less than

$35,740?

IL-1363 front (R-12/00)

Form Il-1363 - Application For Circuit Breaker And Pharmaceutical Assistance - 2000

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