Form Il-1363 - Circuit Breaker And Pharmaceutical Assistance Claim - 1999
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1
2Illinois Department of Revenue
Circuit Breaker and
1999 IL-1363
$
Pharmaceutical Assistance Claim
For households with annual incomes less than $16,000
Official Use Only
Step 1: Tell us about the claimant.
Please print.
1
Social Security number
4 Birth date __ __/__ __/__ __ __ __
Month
Day
Year
2
Name______________________________________________
-
Last
First
MI
5 Phone (____) ___________
3
Address_________________________________ Apt._______
Area code
6 Marital status
City_______________________ State____ ZIP____________
Single, widow(er), or divorced
1
Married and living together
2
7
Does the person named above want Pharmaceutical
Married, but not living together
3
Assistance coverage?
yes
no
Step 2: Tell us about the claimant’s husband or wife.
If none or deceased, go to Step 3.
8
Husband’s or wife’s Social Security number
9
Husband’s or wife’s first name __________________________________
10
Husband’s or wife’s birth date __ __/__ __/__ __ __ __
Month
Day
Year
11
Does the person named on Line 9 want Pharmaceutical
Assistance coverage?
yes
no
Step 3: Tell us your total income for 1999 (include both husband’s and wife’s)
12
Social Security, SSI benefits. Include Medicare deductions (yearly total) . . . . . . . . . . 12
13
Railroad Retirement benefits. Include Medicare deductions (yearly total). . . . . . . . . . 13
14
Civil Service benefits (yearly total). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15
Other pensions and annuity benefits (yearly total). . . . . . . . . . . . . . . . . . . . . . . . . . 15
16
Veterans’ benefits (yearly total). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
17
Human Services benefits (yearly total). See instructions . . . . . . . . . . . . . . . . . . . . . 17
18
Wages, salaries, and tips (yearly total). ____________ + ____________ = . . . . 18
Claimant
Claimant’s husband or wife
19
Interest and dividends received (yearly total) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
20
Net rental, farm, and business income or (loss). Attach U.S. 1040 for loss . . . . . . . . . 20
21
Net capital gain or (loss). Attach U.S. 1040 for loss . . . . . . . . . . . . . . . . . . . . . . . . . 21
22
Other income or (loss). Attach U.S. 1040 for loss . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Step 4: Did you rent out part of your home to someone else?
If not, go to Step 5.
23
How many rooms are there in your home? ________
24
How many rooms did you rent to someone else in 1999? ________
Step 5: Tell us about the Illinois property tax or rent you paid in 1999
25
Property tax you paid in 1999 (both installments) . . . . . . . . . . . . . . . . . . . . . . . . . 25
26
Mobile home tax you paid in 1999 (yearly total) . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
27
Rent you paid in 1999 (yearly total) Does your rent include food?
yes
no . . . . . . . . . 27
28
Nursing, retirement, or shelter care home charges you paid in 1999 (yearly total). . . . 28
Continue with Step 5 on the back of this form.
IL-1363 front (R-12/99)
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Parent category: Financial