Form Il-1363 - Circuit Breaker And Pharmaceutical Assistance Claim

To whom did you pay rent in 1999? (If you had

To whom did you pay nursing, retirement, or shelter

more than one landlord, you must complete the

care home charges in 1999? (If you paid these

following information for each landlord. Attach

charges to more than one institution, you must

additional sheets if necessary.)

complete the following information for each

institution. Attach additional sheets if necessary.)

Name ___________________________________

Name ____________________________________

Address__________________________________

Address___________________________________

_________________________________________

__________________________________________

Phone (_____) _______________

For how many months did you live here in 1999? _______

Area code

For how many months did you rent here in 1999? _____

How much in nursing, retirement, or shelter care

How much rent did you pay here in 1999? ___________

home charges did you pay in 1999?__________________

Note: Do not include an amount paid by a Section 8 program.

Note: Do not include amounts paid by Human Services.

If you now live in Public Housing but last year

lived in private housing, see instructions.

Step 6: Does the claimant qualify as disabled?

If the claimant was 65 years of age or older

before January 1, 2000, go to Step 7.

Did you receive Social Security

If yes and you are a first-time filer, send

disability benefits in 1999? . . . . . . . . . . . . . . yes

us written proof from the Social Security

Administration. Go to Step 7.

Did you receive disability benefits from

If yes, send us a copy of your pension

Railroad Retirement or Civil Service in 1999? . yes

statement indicating that you were totally

disabled or you had a deduction for Medicare.

Go to Step 7.

Did you receive disability benefits from the

If yes, send us a copy of your pension

Veterans Administration in 1999? . . . . . . . . . yes

statement. Go to Step 7.

Did you have a Class 2 disability card from

the Illinois secretary of state’s office in 1999?. . yes

If yes, send us a copy. Go to Step 7.

Note: If you were totally disabled and answered “no” to Questions 31, 32, 33, and 34, your doctor must fill out Step 2

of Schedule A, Doctor’s Statement, and you must attach Schedule A to your Form IL-1363.

Step 7: You must sign this form on the line 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 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 1999 and 2000 for Circuit Breaker and Pharmaceutical Assistance claim

processing. This consent is in effect until such time as I withdraw my authorization. I also hereby assign to the Illinois Department of Revenue

my right to any benefits, including reimbursement, under any 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 in error, I will repay them to the Illinois

Department of Revenue. I authorize exchange of health care information between any drug utilization review service authorized by the

department and any of my physicians and pharmacists to the extent necessary for the operation of a drug utilization review service.

___________________________________________________

Mail to:

Claimant’s signature (If you are able only to make a mark, someone else must sign as witness.) Date

CIRCUIT BREAKER

___________________________________________________

ILLINOIS DEPARTMENT OF REVENUE

PO BOX 19003

Claimant’s husband’s or wife’s signature (If filing together)

Date

SPRINGFIELD IL 62794-9003

________________________________ (_____) ____________

Preparer’s name (Print or type.)

Date

Phone

For information,

call us at 1 800 624-2459

visit our Web site at

Postmark deadline for filing is December 31, 2000.

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. 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

IL-1363 back (R-12/99)

Form Il-1363 - Circuit Breaker And Pharmaceutical Assistance Claim - 1999 Page 2

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