Form Il-1363-X - Amended Application For Form Il-1363 Benefits - 2011
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State of Illinois
Illinois Department on Aging
20_ _ IL-1363-X
Amended Application for Form IL-1363 Benefits
Official use only
A
SECTION
:
Tell us about yourself (claimant).
Please print.
1
5
Social Security number
Birth date
Month
Day
Year
2
6
Name
___________________________________________
Marital status (
only one box)
First
MI
Last
1 Single, widow(er), or divorced
3
Address
_______________________________
Apt.
______
2 Married/civil union and living together
City
______________________
State
____
ZIP
__________
3 Married/civil union, but not living together
4
7
Phone
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Are you
Male
Female
Area Code
B
SECTION
:
Tell us about your spouse.
Spouse includes parties to a civil union.
Complete this section if you checked Marital status 2.
8
8
Your spouse’s Social Security number. .............
9
9
_______________________________________________
Your spouse’s name. .........................................
First
MI
Last
10
10
Your spouse’s birth date. ................................
Month
Day
Year
C
Write only the claimant’s and spouse’s total income for 20_ _ .
SECTION
:
You must include your spouse’s income (if married and living together).
11
11
Social Security, SSI benefits. Include Medicare deductions (yearly total) .....................
12
12
Railroad Retirement benefits. Include Medicare deductions (yearly total) .....................
13
13
Civil Service benefits (yearly total) .................................................................................
14
14
Annuity benefits (yearly total) .........................................................................................
15
15
Other pensions (yearly total) .................. a nontaxable
...... b taxable
16
16
Veterans’ benefits (yearly total) .............. a nontaxable
..... b taxable
17
17
Human Services and other cash public assistance benefits (yearly total) .....................
18
18
$0.00
Wages, salaries, and tips from work (yearly total)
+
=
Claimant
Spouse
19
19
Interest and dividends received (yearly total) ................................................................
20
20
Net farm, business or rental income or (loss). If loss, attach copy of U.S. 1040. .........
21
21
Net capital gain or (loss). If loss, attach copy of U.S. 1040 and Schedule D. .............
22
22
Other income, (loss) or (deductions). If loss or deductions, attach copy of U.S. 1040. ....
- - - - - - - - - - - - -
23
23
This is your total income.
$0.00
Add Lines 11 through 22.
Do not include Lines 15a and 16a in your total.
24
If you rented out any part of your home to someone else, complete Lines 24a and 24b.
_____________
a Number of rooms in your home.
a
_____________
D
b Number of rooms you rented out to someone else.
b
Go to
SECTION
Form IL-1363-X (R-12/11)
1 of 4
Go to Page 2
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