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If you are applying as a disabled person, you must

complete Step 6 on the back of the claim form.

IL-1363 Step-by-Step

Instructions for completing Step 6 begin on Page 9.

Instructions

Telephone number

It may be necessary to call you in order to complete the

Step 1: Tell us about the claimant

processing of your claim form. Please write the area

code and telephone number where you can be reached

If you received a Circuit Breaker and Pharmaceutical

during the day.

Assistance program booklet with your name and address

preprinted on the front cover, you will find your Social

Claimant’s marital status

Security number, name, and address preprinted at the

You must mark one of the marital status boxes printed

top of your claim form on Page 3. Please check to see

on the front of your claim form. For example, if you are

that your Social Security number, name, and address

married and living with your husband or wife, you must

are correct. If any of the information is incorrect, please

mark the box to the left of “Married and living together”

make any necessary corrections next to the preprinted

and complete Step 2.

information.

Does the claimant want Pharmaceutical

If your claim form is not preprinted with your Social

Security number, name, and address, please follow the

Assistance coverage or renewal

instructions for Lines 1, 2, and 3.

coverage?

Send us the completed claim form on Page 3, and fill out

and keep the claim form on Page 17 for your records.

If you want new or renewal Pharmaceutical

Please note that you must use the address where you

Assistance coverage, mark “yes” on Line 7 in the

live.

Pharmaceutical Assistance section in Step 1. The

cost of Pharmaceutical Assistance coverage will be

Social Security number

subtracted from your grant if you receive one. If the

Please write your Social Security number exactly as it

amount of your grant does not cover the cost of

appears on your Social Security card. If you do not have

coverage, we will bill you for the difference.

your own Social Security number, you must apply for

If you wish to pay for your coverage in

one at any Social Security Administration office. You

advance, you may send us a check payable to

must be assigned a Social Security number before you

“Illinois Department of Revenue” in the amount of

send us your Circuit Breaker claim form.

$80 for each individual requesting coverage. If you

Name

overpay, we will refund you the difference.

Please print your name (last name, first name, and

Step 2: Tell us about the claimant’s

middle initial).

husband or wife

Address

Husband’s or wife’s Social Security

Please print your street address, apartment number (if

you have one), city, state, and ZIP code. You must use

number

the address where you live. A change in your address

Write the claimant’s husband’s or wife’s Social Security

can affect the amount of your grant; therefore, we

number. He or she must have his or her own Social

cannot accept the address of your Social Security

Security number. It cannot be the same as the

representative payee, your vacation area, a relative, a

claimant’s.

bank, your trustee, the person who holds your power of

attorney, a conservator, or a post office box number.

Husband’s or wife’s first name

Birth date

Print the claimant’s husband’s or wife’s first name.

Write the month, day, and year of your birth. For

10 Husband’s or wife’s birth date

example, June 30, 1928, should be written as:

Write the claimant’s husband’s or wife’s birth date.

0 6 /3 0 /1 9 2 8

Month

Day

Year

11 Does the person named on Line 9 want

If this is the first time you are filing, you must send us

Pharmaceutical Assistance coverage?

proof of your date of birth.

If your husband or wife wants Pharmaceutical

Examples of proof we will accept are

Assistance coverage, he or she must

copies of your

birth certificate

passport

be living in the same household as you (the

driver’s license

insurance policy

claimant); and

baptismal record

naturalization papers

be 65 years of age or older before January 1, 2000,

or totally disabled in 1999; and

ID card from

secretary of state’s office

IL-1363 instructions (R-12/99)

Page 5 of 12

Form Il-1363 Instructions - Circuit Breaker And Pharmaceutical Assistance - Illinois Department Of Revenue Page 5

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