Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, And Optional Help Paying For Drugs (Pharmaceutical Assistance Or Seniorcare) - 2004 Page 11
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205a
7 Marital status
Check the box on Line 5a if you want to apply for
Pharmaceutical Assistance or SeniorCare
Check only one of the marital status boxes on
benefits.
Line 7.
If you want to apply for help paying for your
1 Single, widow(er), or divorced
drugs, remember to check the box in Line 5a.
if you are single, or
•
Also, do not send us any payment with your
•
if your spouse was deceased before
Form IL-1363.
January 1, 2005*, or
5b
Complete Line 5b only if you are 65 years of age
•
if you were divorced before
or older (or if you will become 65 years of age
January 1, 2005.
during 2005) and you want to apply for
*If your spouse was living with you during 2004,
SeniorCare benefits.
you must include his or her income in Step 3.
Check the first box if you are a U.S. citizen.
Check the second box if you are a qualified
2 Married and living together
noncitizen. See Page 7 “SeniorCare requirements
•
if you were married and living with your
for noncitizens” to find out if you qualify to check
spouse during 2004, or
the second box.
•
if your spouse died in 2005, but was
If you check the second box,
living with you during 2004 (you must
you may need to send us proof of your
provide a copy of the death certificate).
qualified noncitizen status — see Page 17.
If you do not check any box in Line 5b, you
3 Married, but not living together
may still get Pharmaceutical Assistance (check
•
if you were permanently separated from
the box in Line 5a), the Circuit Breaker grant, or a
your spouse during 2004, or
license plate discount.
•
if you or your spouse were living in a
nursing, retirement, or shelter care
6 Birth date
home in 2004.
Write the month, day, and year of your birth. For
example, June 30, 1934, should be written as:
8
Tell us if you are male or female
0 6 /3 0 /1 9 3 4
Check the box that applies to you.
Month Day
Year
If this is the first time you are applying,
you must send us proof of your age —
see Page 17.
If you are younger than age 65, you must be
disabled to qualify and
you must send us proof of your
disability — see Page 17.
Step 2:
Tell us about your spouse (husband or wife).
Complete Step 2 only if you checked Marital status 2,
10 Spouse’s name
“Married and living together” on Line 7. Otherwise, if
Print your spouse’s first name, middle initial, and
you do not have a spouse, if your spouse is deceased,
last name.
or if you are not living in the same household as your
11 Spouse’s birth date
spouse, skip to Step 3.
Write the month, day, and year of your spouse’s
9 Spouse’s Social Security number
birth.
Write your spouse’s (husband’s or wife’s) Social
If this is the first time your spouse is applying,
Security number. Your spouse must have his or
you must send us proof of your
her own Social Security number. It cannot be the
spouse’s age — see Page 17.
same as yours.
11
Apply every year
Renew by March 31
IL-1363 instructions (R-12/04)
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