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mark “yes” in the Pharmaceutical Assistance

state income tax refunds (as shown on

section in Step 2, Line 11, on the front of the Circuit

Form 1099-G)

Breaker claim form.

unemployment compensation

If this is the first time your husband or wife is applying

veterans’ benefits

for Pharmaceutical Assistance coverage and he or she

wages, salaries, and tips

is at least 65 years of age, he or she must send proof of

What is not income?

date of birth. For examples of proof of date of birth we

will accept, see Page 5.

On your Form IL-1363, do not include the following as

If your husband or wife is under age 65, he or she must

income:

be totally disabled to qualify for Pharmaceutical

cash gifts

Assistance coverage; your husband or wife must send

child support payments

us proof of disability. Examples of proof we will accept

Circuit Breaker grants

can be found on Page 9 of this booklet.

damages awarded from a lawsuit on account of a

If you are entitled to a Circuit Breaker grant, we will

physical personal injury or sickness

withhold the cost of his or her coverage from the grant

Energy Assistance payments

as payment. If the amount of your grant does not cover

federal income tax refunds

the cost of the coverage, we will bill you for the

IRA’s “rolled over” into other retirement accounts

difference.

lump sums from inheritances

If you wish to pay for your coverage in

lump sums from insurance policies

advance, you may send us a check payable to

money borrowed against a life insurance policy or

“Illinois Department of Revenue” in the amount of

from any financial institution

$80 for each individual requesting coverage. If you

reverse mortgage income

overpay, we will refund you the difference.

stipends from the Foster Parent and Foster

Step 3: Tell us your total income

Grandparent programs

Worker’s Compensation

for 1999 (include both husband’s

12 Social Security, SSI benefits

and wife’s)

Write the total of any retirement, disability, or survivor’s

What is income?

benefits (including Medicare deductions) paid to you and

your husband or wife in 1999 by the Social Security

On your Form IL-1363, you must include the following as

Administration. You must include any Supplemental

income:

Security Income (SSI) you received in 1999. Do not

alimony

include benefits to dependent children or

Black Lung benefits

reimbursements under Medicare/Medicaid for medical

business income

expenses.

capital gains

It is not necessary to contact the Social Security

cash assistance from Human Services

office to obtain the amount in benefits received. You

cash winnings from such sources as

can determine the total amount of your benefits by

raffles or lotteries

multiplying the amount of any one of the checks you

received in 1999 by 12. Add to this total $546.00 (or

Civil Service benefits

$45.50 per month), which was the yearly amount

damages awarded in a lawsuit on account of

deducted for Medicare. You must adjust your figures

nonphysical injury or sickness (for example, age

accordingly if you did not receive 12 equal checks during

discrimination or injury to reputation)

this period.

dividends

If your Social Security and Railroad Retirement benefits

farm income

are paid to you on the same check, write this amount on

interest

Line 12. Remember to include your Medicare

interest on life insurance policies

deductions.

lump sum Social Security payments

13 Railroad Retirement benefits

miscellaneous sources, such as rummage

Write the total of any retirement, disability, or survivor’s

sales, recycling aluminum, or baby sitting

benefits (including Medicare deductions) you and your

monthly insurance benefits

husband or wife received in 1999 under the Railroad

pension, annuity, and IRA benefits

Retirement Act. If you have included your Railroad

Railroad Retirement benefits

Retirement benefits on Line 12, do not fill out Line 13.

rental income

Social Security income (including Medicare

deductions)

SSI benefits

Page 6 of 12

IL-1363 instructions (R-12/99)

Form Il-1363 Instructions - Circuit Breaker And Pharmaceutical Assistance - Illinois Department Of Revenue Page 6

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