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If you can provide any other information to explain

If you are disabled, follow the instructions

how you are able to pay high rent on a limited

in Step 6 on Page 9.

income, please explain on a separate sheet of

How does my husband or wife also apply

paper.

for Circuit Breaker?

Do I qualify if my husband or wife dies?

If you and your husband or wife live together, you must

If your husband or wife dies and he or she was the

declare your total household income on one Circuit

household member who had been applying for the grant

Breaker claim form. Your husband or wife cannot file

but had not completed a claim for 1999 prior to death,

separately.

you must file a 1999 claim form in your own name. You

If one or both of you live in a nursing home, you may

may be considered eligible for the Circuit Breaker grant

each file separate claim forms.

and/or Pharmaceutical Assistance coverage if you

If you and your husband or wife were permanently

turned 63 before the date of your husband’s or wife’s

separated in 1999 and are still living at different

death. You must also meet all other qualifications listed

addresses, you may each file separate claim forms.

on Page 1. Please send us a copy of your husband’s or

wife’s death certificate and proof of your date of birth.

What if I share my home with someone

Examples of proof we will accept can be found on

other than my husband or wife?

Page 5 of this booklet. You must also write on Line 22

the amount in income your husband or wife received

Only a husband and wife are considered to be in the

during the months he or she was living with you.

same household, and they must combine their income

If your husband or wife dies in 2000 after he or she has

on one claim form. If someone other than your husband

filed a properly completed 1999 claim, you may request

or wife lives with you and is qualified, that person is

that we send the Circuit Breaker check to you. You must

eligible to apply for his or her own Circuit Breaker grant.

have been living with your husband or wife at the time he

You must declare as income any rent he or she paid to

or she filed the claim. Please send us a copy of the

you.

death certificate. If there is no surviving husband or wife,

What if my income is not much more than

we will reissue the check to any surviving dependent

children under age 18 who were living with the claimant

the property tax or rent I paid?

at the time he or she filed the claim. Otherwise, the

Some claimants may have a very low income and high

check must be returned to us.

property taxes or rent. If this situation applies to you and

How do I get a vehicle license

you own your home, please send us a copy of your

property tax bill, receipts from your county government,

discount card?

or cancelled checks documenting the property tax you

In order to be eligible for a discount on your vehicle

paid in 1999. If you are a renter, send us a copy of your

license for a given year, you must have met the Circuit

rental agreement, a notarized statement from your

Breaker qualifications for the previous year (see

landlord, or cancelled checks documenting the rent you

Page 1). We process Circuit Breaker claim forms and

paid in 1999. In addition, please send us the following

forward approval information to the secretary of state’s

information to explain how you were able to pay your

office. For further information,

expenses.

Indicate whether family or friends paid your rent or

write:

SECRETARY OF STATE

whether your rent was subsidized. List only the

RENEWALS SECTION

amount you paid.

RM 500 HOWLETT BLDG

Do not list rent owed but not paid in 1999.

SPRINGFIELD IL 62756-7000

If you shared your home with someone other than

or call: 1 800 252-2904

your husband or wife, list only your portion of

property tax or rent.

217 785-9364

If someone lived with you and paid you rent in

1999, list the amount you received in rental income

on Line 20 and complete Step 4.

If your rent included food, mark “yes” on Line 27.

If you can provide information about minor

dependent children receiving Social Security, SSI,

or child support, please explain on a separate

sheet of paper. These types of benefits are not

considered income, but you must report them to

explain how you are able to meet your expenses.

Reporting these benefits will help prevent delays in

your Circuit Breaker grant or Pharmaceutical

Assistance coverage.

Page 2 of 12

IL-1363 instructions (R-12/99)

Form Il-1363 Instructions - Circuit Breaker And Pharmaceutical Assistance - Illinois Department Of Revenue Page 2

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