Instructions And Benefits Information For Form Il-1363 - Illinois Department Of Revenue - 2002 Page 16
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2031 Nursing, retirement, or shelter care
31a To whom did you pay nursing,
retirement, or shelter care home
home charges you paid in 2002
charges in 2002?
Complete Line 31 only if you consider the
Write the name, address, and telephone
nursing, retirement, or shelter care home as your
number of the nursing, retirement, or
principal or permanent residence. Write the total
shelter care home to whom you paid these
amount in charges you paid in 2002. Do not
charges.
include amounts paid to the home by the Illinois
Department of Human Services, any medical
31b How many months did you live here in
assistance programs, or your insurance company.
2002?
Write the number of months during which
you lived in this home.
Step 6:
Sign below.
32 Your (the claimant’s) signature
33 Spouse’s signature
You must sign and date the application on
If you are married and living with your spouse,
Line 32. If you are only able to make a mark,
your spouse must sign and date Form IL-1363 on
another person must sign as a witness. If you
Line 33. If your spouse is able only to make a
are unable to sign, your legal representative may
mark, another person must sign as a witness. If
your spouse is unable to sign, your spouse’s legal
sign for you. However, you must attach
representative may sign. However, you must
documentation to Form IL-1363 each time you
attach documentation to the application each time
apply proving that the representative is your
you apply for your spouse, proving that the
legal guardian or has power of attorney to act for
representative is your spouse’s legal guardian or
you. Applications without a valid signature or
has power of attorney to act for your spouse.
mark will not be approved.
Applications without a valid signature or mark will
If the claimant is not yet age 18, the
not be approved.
claimant’s parent or guardian must sign on
34 Preparer’s name
Line 32, indicating the relationship to the claimant
(such as “mother,” “father,” or “guardian”).
If someone, other than you or your spouse, such
as a son, daughter, or legal representative,
prepares this form for you, that person should
print or type his or her name and telephone
number on Line 34.
16
Avoid a delay
Apply by March 31
IL-1363 instructions (R-12/02)
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