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18 Wages, salaries, and tips

14 Civil Service benefits

Write the total amount in wages, salaries, and tips you

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

received in 1999 from working and the total amount your

benefits you and your husband or wife received in 1999

husband or wife received in 1999 from working. Add the

under any Civil Service retirement plan.

two individual totals together, and write the total amount

15 Other pensions and annuity benefits

on Line 18. If you filed a federal income tax return, this

information is on your U.S. Form 1040, 1040A, or

Write the total income you received in 1999 from any

1040EZ.

annuity, pension, IRA, endowment, life insurance or

similar plan, or agreement you and your husband or wife

19 Interest and dividends received

held. (Shown on Form 1099-R). Include only the taxable

Write the total amount in interest and dividends you and

portion of IRA’s, IRA’s converted to Roth IRA’s,

your husband or wife received in 1999 from all sources,

pensions, and annuities. (Shown on U.S. 1040, Line 15b

including any government sources.

and 16b, or U.S. 1040A, Line 10b and 11b.) IRA’s are

20 Net rental, farm, and business income or

considered income when withdrawn, but not when “rolled

over.”

(loss)

16 Veterans’ benefits

Write any net income or loss from rental, farm, and

business sources. Please attach a copy of your U.S.

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

Form 1040 as proof of any loss you report. If you did not

benefits you and your husband or wife received in 1999

file a U.S. Form 1040, you must send us a detailed

from the Veterans Administration.

explanation of the loss and how you figured it.

17 Human Services benefits

A loss should be placed in parentheses. For example, a

Write the total amount in Human Services cash

$700 loss should be written as (700).

assistance you and your husband or wife received in

21 Net capital gain or (loss)

1999. If the first two digits of your case number are the

same as any of those in the following list, you must

Write any net capital gain or loss you and your husband

include the total amount of any of these benefits on Line

or wife received in 1999.

17.

If you report a net capital loss, it must not exceed

01 aged

$3,000. If you are married, but not living with your

husband or wife, and filing both a U.S. Form 1040 and a

02 blind

Circuit Breaker claim in your name only, your net capital

03 disabled

loss should not exceed $1,500. Please attach a copy of

04 temporary assistance to needy families

your U.S. Form 1040 as proof of any loss you report. If

(TANF)

you did not file a U.S. Form 1040, you must send us a

06 temporary assistance to needy families

detailed explanation of the loss and how you figured it.

(TANF)

A loss should be placed in parentheses. For example, a

07 general assistance

$700 loss should be written as (700).

It is not necessary to contact the Human Services

22 Other income or (loss)

office to obtain the amount in benefits received. You

Write any other income or loss not reported on Lines 12

may determine the total amount of your benefits by

through 21. For an explanation of other income, see

multiplying the amount of any one of the checks you

“What is income?” on Page 6. Please attach a copy of

received in 1999 by 12. You must adjust your figures

your U.S. Form 1040 as proof of any loss you report. If

accordingly if you did not receive 12 equal checks during

you did not file a U.S. Form 1040, you must send us a

this period. If for some reason you are unable to write an

detailed explanation of the loss and how you figured it.

amount on Line 17 and you did receive Human Services

A loss should be placed in parentheses. For example, a

benefits, write “yes” in the space provided.

$700 loss should be written as (700).

In the aged, blind, and disabled categories, your Circuit

Breaker grant will be reduced in proportion to the

You may not use a net operating loss

number of months you receive cash assistance of more

carryover (NOL) in figuring income for purposes of

than $55. For example, if you received, in any of these

Circuit Breaker grants.

categories, more than $55 per month in cash assistance

Step 4: Did you rent out part of

for four months (one-third of the year), the amount of

your grant would be reduced by one-third. If you

your home to someone else?

received cash assistance of more than $55 per month

from Human Services for all 12 months of 1999, you

23 How many rooms are there in your home?

would not be eligible for a Circuit Breaker grant.

If you were a homeowner or renter and rented out part of

Food stamps and medical assistance you may have

your home to someone else, you must write the total

received are not considered income and will not be

number of rooms in your home.

added to your total income.

IL-1363 instructions (R-12/99)

Page 7 of 12

Form Il-1363 Instructions - Circuit Breaker And Pharmaceutical Assistance - Illinois Department Of Revenue Page 7

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