Form Il-1363 - Application For Circuit Breaker And Pharmaceutical Assistance

Step 5: Tell us about the Illinois property tax or rent you paid in 2001.

25 Property tax you paid in 2001

. ............................................... 25

(both installments)

26 Mobile home tax you paid in 2001

. .................................................. 26

(yearly total)

27 Rent you paid in 2001

Does your rent include food? yes

(yearly total).

To whom did you pay rent in 2001?

Name __________________________________________ Phone (__ __ __) __ __ __ - __ __ __ __

Address ________________________________________ City_______________________State_____ZIP________

How many months did you rent here in 2001?

______________

If you had more than one landlord, attach a sheet with the information requested on Lines 27a and 27b

above for each one.

Do not include amounts paid by a Section 8 program.

If you now live in public housing, but last year lived in private housing, see the instructions for Line 27.

28 Nursing, retirement, or shelter care home charges you paid in 2001

. .. 28

(yearly total)

To whom did you pay nursing, retirement, or shelter care home charges in 2001?

Name __________________________________________ Phone (__ __ __) __ __ __ - __ __ __ __

Address ________________________________________ City_______________________State_____ZIP________

How many months did you live here in 2001?

______________

If you lived in more than one nursing, retirement, or shelter care home, attach a sheet with the

information requested on Lines 28a and 28b above for each one.

Do not include any amounts paid by Human Services.

Step 6: Sign below.

Under penalties of perjury, I state that I have examined this form and, to the best of my knowledge, it is true, correct, and complete. I give the Illinois Department of

Revenue (IDOR) permission to get records from anyone concerning information I have placed on this form. I also assign to IDOR my right to any benefits, including

reimbursement, under any private plan of assistance, public assistance program, insurance plan, or from any liable third party, for prescription drugs that I receive

through the Pharmaceutical Assistance program. I also agree that if I receive any such payments or other payments or benefits under this program in error, or that I

was not entitled to, I will repay them to IDOR. I authorize release of medical and pharmaceutical records for audit and verification purposes, and exchange of health

care information between any drug utilization review service authorized by IDOR and any of my physicians and pharmacists to the extent necessary for the

operation of a drug utilization review service.

29 ______________________________/___/___

31 ________________________(____)________

Claimant’s signature

Date

Preparer’s name (Please print.)

Phone number

30 ______________________________/___/___

Spouse’s signature (If living together)

Date

If you need additional assistance

• call us at 1 800 624-2459, or

• visit our Web site at

• call our TDD (telecommunications device for the

deaf) at 1 800 544-5304

Use this checklist to help avoid delays in receiving your benefits

If applying for Pharmaceutical Assistance coverage, be

Be sure to send us any required attachments. See

sure that you checked the applicable box on

“You may need to attach.”

• Line 5 for yourself,

Be sure to have all of the required signatures

• Line 11 for your spouse, and

• Line 29 for yourself,

• Schedule B for any qualified additional resident.

• Line 30 for your spouse, and

If applying for Pharmaceutical Assistance coverage for

• Schedule B, Step 4, for any qualified additional

the first time for yourself, your spouse, or any qualified

resident, along with your signature in Step 3.

additional resident, be sure to attach your payment.

Be sure you mail your application, required

attachments, schedules, and payment, if applicable, to

the correct address, both of which are shown below.

If applying for Pharmaceutical Assistance coverage

If NOT applying for Pharmaceutical Assistance coverage

ILLINOIS DEPT OF REVENUE/PHARMACEUTICAL

ILLINOIS DEPT OF REVENUE/CIRCUIT BREAKER

PO BOX 19022

PO BOX 19003

SPRINGFIELD IL 62794-9022

SPRINGFIELD IL 62794-9003

This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act. Disclosure of this information is REQUIRED.

Failure to provide information could delay your grant and pharmaceutical coverage. This form has been approved by the Forms Management Center.

IL-492-2740

IL-1363 back (R-12/01)