Instructions And Benefits Information For Form Il-1363 - Illinois Department Of Revenue - 2002 Page 10
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20Form IL-1363 — line-by-line instructions
Step 1:
Tell us about yourself (claimant).
5a Check the box if you want prescription
If you received a Form IL-1363 booklet with your
name and address preprinted on the front cover,
coverage or the SeniorCare rebate
please check the preprinted information at the
Check the box on Line 5a if you want to apply for
top of your Form IL-1363, Application for Circuit
Pharmaceutical Assistance or SeniorCare
Breaker and Prescription Coverage, to make
(prescription coverage or the insurance rebate).
sure that your Social Security number, name,
Do not send us any payment with your
and address where you live are correct.
Form IL-1363.
If any of the information is incorrect, please
5b Check the “Yes” box if you are a U.S.
make any necessary corrections next to the
citizen.
preprinted information. Send us the completed
Complete Line 5b only if you are 65 years of age
application, and be sure to keep a copy for your
or older or if you will become 65 years of age
records.
during 2003. If yes, check the “Yes” box.
If your Form IL-1363 is not preprinted with your
5c If you are not a U.S. citizen, determine
Social Security number, name, and address
where you live, follow the instructions for
which box to check.
Lines 1, 2, and 3.
Complete Line 5c only if you are 65 years of age
or older or if you will become 65 years of age
1
Social Security number
during 2003.
Write your Social Security number exactly as it
Check Box 1 if you are not a U.S. citizen and
appears on your Social Security card. If you do
you are one of the following:
not have your own Social Security number, you
• lawful permanent resident who has lived in
may apply for one at any Social Security
the U.S. for at least five years
Administration office. You must be assigned a
• refugee
Social Security number before you send us your
Form IL-1363.
• asylee
• parolee
2
Name
• your deportation is being withheld
Print your first name, middle initial, and last name.
• not a citizen but a U.S. veteran
3
Address
If you check Box 1,
Print your street address and apartment number
you must send us proof of your
(if you have one), your city, state, and ZIP code.
immigration status — see Page 17.
You must use the address where you live.
Check Box 2 if you are not a U.S. citizen and
A change in your address can affect the amount
you do not qualify to check Box 1.
of your grant. Therefore, we cannot accept the
address of your Social Security representative
6
Birth date
payee, your vacation area, a relative, a bank,
Write the month, day, and year of your birth. For
your trustee, the person who holds your power of
example, June 30, 1934, should be written as:
attorney, a conservator, or a post office box
0 6 /3 0 /1 9 3 4
number.
Month Day
Year
If this is the first time you are applying,
4
Phone number
you must send us proof of your age —
Write the area code and phone number where
see Page 17.
we can reach you during the day. It may be
If you are younger than age 65, you must be
necessary to call you in order to complete the
disabled to qualify and
processing of your application.
you must send us proof of your
disability — see Page 17.
10
Avoid a delay
Apply by March 31
IL-1363 instructions (R-12/02)
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