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12a If you want to apply for Pharmaceutical

12b Complete Line 12b only if your spouse is 65

Assistance or SeniorCare benefits for your

years of age or older or will become 65 years of

spouse, check the box on Line 12a. (To be

age during 2005, and you want to apply for

eligible for drug coverage, your spouse must

SeniorCare benefits for your spouse.

meet the requirements listed on Page 2, “Who

Check the first box if your spouse is a U.S.

should apply?”.)

citizen.

If your spouse is disabled and younger than 65

Check the second box if your spouse is a

years of age,

qualified noncitizen. See Page 7 “SeniorCare

you must send us proof of your

requirements for noncitizens” to find out if your

spouse’s disability — see Page 17.

spouse is a qualified noncitizen.

If you want to apply for help paying for your

If you check the second box for your spouse,

drugs, remember to check the box in Line 12a.

you may need to send us proof of your

Also, do not send us any payment with your

spouse’s noncitizen status — see

Form IL-1363.

Page 17.

If you do not check any box in Line 12b,

your spouse may still get Pharmaceutical

Assistance (check the box in Line 12a).

Step 3:

Write only the claimant’s and spouse’s total income for 2004.

Include only your income and your spouse’s income (if

Railroad Retirement benefits (including

you were living together) for the year 2004. Do not

Medicare deductions)

include any qualified additional resident’s income.

rental income

SeniorCare rebate received in 2004 (only if you

What is considered income?

took an itemized deduction for health insurance on

You must include items that are considered income for

your 2003 federal income tax return)

2004 federal income tax purposes. Examples are:

Social Security income (including Medicare

alimony

deductions)

annuity benefits

Supplemental Security Income (SSI) benefits

Black Lung benefits

state income tax refunds received in 2004 (only if

business income

you took an itemized deduction on your 2003

capital gains

federal income tax return)

cash assistance from the Illinois Department of

unemployment compensation

Human Services and other governmental cash

veterans’ benefits (only the federally taxable portion)

public assistance

wages, salaries, and tips from work

cash winnings from such sources as raffles,

Workers’ Compensation Act income

lotteries, or gambling

Workers’ Occupational Diseases Act income

Civil Service benefits

damages awarded in a lawsuit on account of

What is not considered income?

nonphysical injury or sickness (for example, age

The following items are not considered income and

discrimination or injury to reputation)

you should not include them on your Form IL-1363:

dividends

cash gifts

farm income

child support payments

interest

Circuit Breaker grants

interest on life insurance policies

damages awarded in a lawsuit for a physical

lump sum Social Security payments

personal injury or sickness

miscellaneous sources, such as rummage sales,

Energy Assistance payments

recycling aluminum, or baby sitting

federal income tax refunds

monthly insurance benefits

IRAs “rolled over” tax-free into other retirement

pension and IRA benefits (only the federally

accounts

taxable portion)

lump sums from inheritances

qualified long term care insurance contract payments

lump sums from insurance policies

(only the federally taxable portion)

Apply every year

Renew by March 31

IL-1363 instructions (R-12/04)

Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, And Optional Help Paying For Drugs (Pharmaceutical Assistance Or Seniorcare) - 2004 Page 12

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