Form Il-1363 - Circuit Breaker Application - 2003
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Illinois Department of Revenue
2003 IL-1363
Circuit Breaker Application
For Circuit Breaker grant, license plate discount, and optional
help paying for drugs (Pharmaceutical Assistance or SeniorCare)
Official use only
Postmark deadline for filing is December 31, 2004.
Step 1: Tell us about yourself (claimant).
Please print.
1
6
Social Security number
Birth date __ __/__ __/__ __ __ __
Month
Day
Year
2
7
Name_______________________________________________
Marital status (
only one box)
First
MI
Last
Single, widow(er), or divorced
1
3
Address__________________________________ Apt._______
Married and living together
2
City_______________________ State_____ ZIP_____________
Married, but not living together
3
4
8
Phone (__ __ __) __ __ __ - __ __ __ __
Are you
Male
Female
Area code
See instructions for
5
a
Yes, I want help paying for my drugs.
(If yes,
the Yes box. If no, skip to Line 6.)
more information.
b For SeniorCare drug coverage, also tell us if you are a
U.S. citizen or
qualified noncitizen.
You may still get Pharmaceutical Assistance and other benefits even if no box is checked in Line 5b.
Step 2: Tell us about your spouse (husband or wife).
Complete this step if you checked Marital status 2.
9
9
Write your spouse’s Social Security number. .......
10
10
Write your spouse’s name. .................................
_________________________________________
First
MI
Last
11
11
Write your spouse’s birth date. ...........................
__ __/__ __/__ __ __ __
Month
Day
Year
See instructions for
12
a
Yes, I want help paying for drugs for my spouse.
(If yes,
the Yes box.)
more information.
b For SeniorCare drug coverage, also tell us if your spouse is a
U.S. citizen or
qualified noncitizen.
Your spouse may still get Pharmaceutical Assistance even if no box is checked in Line 12b.
Step 3: Write only the claimant’s and spouse’s total income for 2003.
13
13
Social Security, SSI benefits. Include Medicare deductions (yearly total) .......................
14
14
Railroad Retirement benefits. Include Medicare deductions (yearly total) .......................
15
15
Civil Service benefits (yearly total) ......................................................................................
16
16
Annuity benefits (yearly total) ...............................................................................................
17
17
Other pensions (yearly total) .................... a nontaxable
........ b taxable
18
18
Veterans’ benefits (yearly total) ................ a nontaxable
........ b taxable
19
19
Human Services and other cash public assistance benefits (yearly total) ..........................
20
20
Wages, salaries, and tips from work (yearly total)
+
=
Claimant
Spouse
21
21
Interest and dividends received (yearly total) .....................................................................
22
22
Net rental, farm, and business income or (loss). If loss, attach copy of U.S. 1040. ...........
23
23
Net capital gain or (loss). If loss, attach copy of U.S. 1040. ..........................................
24
24
Other income or (loss). If loss, attach copy of U.S. 1040. ...............................................
25 Add Lines 13 through 24. This is your total income.
25
Do not include Lines 17a and 18a in your total.
26
If you rented out any part of your home to someone else, complete Lines 26a and 26b.
_____________
a Write the number of rooms in your home.
a
_____________
b Write the number of rooms you rented to someone else. b
IL-1363 front (R-12/03)
Go to Page 2
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