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

Step 5: Tell us about the Illinois property tax or rent you paid in 2000.

25 Property tax you paid in 2000

. ................................................ 25

(both installments)

26 Mobile home tax you paid in 2000

. .................................................. 26

(yearly total)

27 Rent you paid in 2000

........ 27

Does your rent include food? yes

(yearly total).

To whom did you pay rent in 2000?

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

Address ________________________________________ City_______________________State_____ZIP________

How many months did you rent here in 2000?

______________

How much rent did you pay here in 2000?

______________

If you had more than one landlord, attach a sheet with the information requested on Lines 27a through 27c 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 27.

28 Nursing, retirement, or shelter care home charges you paid in 2000

. .. 28

(yearly total)

To whom did you pay nursing, retirement, or shelter care home charges in 2000?

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

Address ________________________________________ City_______________________State_____ZIP________

How many months did you live here in 2000?

______________

How much in nursing, retirement, or shelter care home

charges did you pay here in 2000?

______________

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

on Lines 28a through 28c above for each one.

Do not include any amounts paid by Human Services.

Step 6:

Step 6: Figure the cost of your Pharmaceutical Assistance coverage.

Go to Step 7 if

not applying for

29 Write the total number of persons applying for Pharmaceutical Assistance coverage,

coverage.

including yourself and your spouse (from the boxes checked on Lines 5 and 11),

and any qualified additional residents (from Schedule B, Line 42). ..................... 29

30 Multiply the number on Line 29 by $25.00 and write the total here.

This is the maximum cost of your Pharmaceutical Assistance coverage. .......... 30 ______________

Send us a check or money order for the amount on

Get your

Line 30, payable to “Illinois Department of Revenue.”

coverage fast

(If you pay too much, we will refund you the difference.)

Your coverage may be delayed if you choose not to send us your payment. See the instructions.

Step 7: 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 Illinois Department of

Revenue (IDOR) permission to get records from anyone, including the Social Security Administration, concerning information I have placed on this form. This consent

includes my authorization for the Social Security Administration to release my Social Security number, name, date of birth, and payment amounts for calendar years

2000, 2001, and 2002, for Circuit Breaker and Pharmaceutical Assistance application processing. This consent is in effect until such time as I withdraw my authorization.

I also assign to IDOR 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. I also agree that if I receive any such payments or other payments

or benefits under this program in error, or that I was not entitled to, I will repay them to IDOR. 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 IDOR and any of my physicians and

pharmacists to the extent necessary for the operation of a drug utilization review service.

31 ______________________________/___/___

If applying for Pharmaceutical Assistance coverage

Claimant’s signature

Date

IL Dept. of Revenue/Pharmaceutical

PO Box 19022

32 ______________________________/___/___

Springfield, Illinois 62794-9022

Spouse’s signature (If living together)

Date

If applying for Circuit Breaker only

33 __________________________(___)_______

IL Dept. of Revenue/Circuit Breaker

Preparer’s name (Please print.)

Phone

PO Box 19003

For information

visit our Web site at

Springfield, Illinois 62794-9003

call us at 1 800 624-2459

call our TDD (telecommunications device for the deaf) at 1 800 544-5304

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.

IL-1363 back (R-12/00)

Failure to provide information could delay your grant and/or pharmaceutical coverage. This form has been approved by the Forms Management Center.

IL-492-2740