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pension statement from that agency stating that you

Step 6: Does the claimant qualify

were totally disabled in 1999.

as disabled?

34 Did you have a Class 2 disability card

You should apply as disabled if you

from the Illinois secretary of state’s

were at least 16 years of age before January 1,

office in 1999?

2000, and you will still be under 65 years of age

before January 1, 2001; or

If you mark “yes” and were at least age 16 but under age

turn 65 years of age during 2000.

65 on January 1, 2000, we will accept a copy of your

To apply as disabled, you must have been totally

Class 2 disability card as proof of your disability.

disabled in 1999.

If you answer “no” to Questions 31, 32,

Examples of proof of disability we will

33, and 34, please have your doctor fill out Step 2

accept are

of Schedule A, Doctor’s Statement.

Social Security attachments:

Step 7: You must sign this form

- Form SSA 1099 showing a Medicare

deduction; or

35 Claimant’s signature

- a statement showing SSI benefits; or

- a statement showing a Medicare

You must sign and date the claim form on Line 35. If you

deduction

are unable to sign, your legal representative may sign for

a letter from the Veterans Administration

you. However, documentation must be attached to the

verifying

claim each time you file proving that the representative is

- your receipt of a disability pension; or

your legal guardian or has power of attorney to act for

- receipt of compensation rated at 100

you. If you are able only to make a mark, one other

percent

person must sign as a witness. Claims without a valid

a letter of verification from Civil Service or

signature or mark will not be paid.

Railroad Retirement disability programs

If the claimant is under age 18, the

a copy of your Class 2 disability card from the

Illinois secretary of state’s office

claimant’s parent or guardian must sign on Line 35,

a completed Schedule A, Doctor’s Statement,

indicating the relationship to the claimant (such as

which can be used either by the claimant or by

“mother,” “father,” or “guardian”).

the claimant’s husband or wife as needed

36 Claimant’s husband’s or wife’s signature

Beginning January 1, 1997, Social Security

If you (the claimant) are married and living with your

Administration guidelines do not include alcoholism or

husband or wife, your husband or wife must sign and

drug abuse as a qualification for disability status.

date the claim form on Line 36. If he or she is unable to

31 Did you receive Social Security disability

sign, his or her legal representative may sign. However,

benefits in 1999?

documentation must be attached to the claim proving

that the representative is his or her legal guardian or has

If you mark “yes,” were at least age 16 but under age 65

power of attorney to act. If he or she is able only to make

on January 1, 2000, and have not been paid a Circuit

a mark, one other person must sign as a witness. Claims

Breaker grant for 1998, you must send us written proof

without a valid signature or mark will not be paid.

from the Social Security Administration stating that you

received disability benefits in 1999.

If someone other than your husband or wife,

If you mark “yes,” were at least age 16 but under age 65

such as a son, daughter, or legal representative,

on January 1, 2000, and filed a Circuit Breaker claim for

prepares this form for you, he or she should print or type

1998 before November 1, 1999, you do not need to send

his or her name and telephone number on the line

us written proof.

provided.

32 Did you receive disability benefits from

Railroad Retirement or Civil Service in

1999?

If you mark “yes” and were at least age 16 but under age

65 on January 1, 2000, you must attach a copy of your

pension statement from that agency stating that you

were totally disabled in 1999 or you had a deduction for

Medicare.

33 Did you receive disability benefits from

the Veterans Administration in 1999?

If you mark “yes” and were at least age 16 but under age

65 on January 1, 2000, you must attach a copy of your

IL-1363 instructions (R-12/99)

Page 9 of 12

Form Il-1363 Instructions - Circuit Breaker And Pharmaceutical Assistance - Illinois Department Of Revenue Page 9

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