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money borrowed against a life insurance policy

2004 from any IRAs, IRAs converted to Roth

or from any financial institution

IRAs, and pensions.

reverse mortgage payments

b Write the total of the federally taxable portion

spousal impoverishment payments

received by you and your spouse in 2004 from

stipends from the Foster Parent and Foster

any IRAs, IRAs converted to Roth IRAs, and

Grandparent programs

pensions.

Title V of the Older Americans Act of 1965;

You may need to attach proof of

Green Thumb or Experience Works; or VISTA

taxable and nontaxable benefits —

or AmeriCorps income

see Page 18.

18 Veterans’ benefits

13 Social Security, SSI benefits

a Write only the federally nontaxable portion of

Write the total amount of any retirement, disability,

any retirement pay or survivor’s benefits you and

or survivor’s benefits (including Medicare

your spouse received in 2004 from the Veterans

deductions) paid to you and your spouse in 2004

Administration.

by the Social Security Administration.

b Write only the federally taxable portion of any

You must also include any Supplemental Security

retirement pay or survivor’s benefits you and

Income (SSI) you received in 2004. Do not

your spouse received in 2004 from the Veterans

include benefits to dependent children or

Administration.

reimbursements under Medicare/Medicaid for

You may need to attach proof of

medical expenses.

taxable and nontaxable benefits —

It is not necessary to contact the Social Security

see Page 18.

office to obtain the amount in benefits received. To

19 Human Services and other governmental

determine the total amount of your benefits,

cash public assistance benefits

multiply by 12 the amount of any one of the

checks you received in 2004. Add to this total

Write the total amount of Illinois Department of

$799.20 (or $66.60 per month), which was the

Human Services and all other governmental cash

yearly amount deducted for Medicare. You must

public assistance benefits you and your spouse

adjust your figures accordingly if you did not

received in 2004.

receive 12 equal checks during this period.

If the first two digits of your Human Services case

number are the same as any of those in the

If your Social Security and Railroad

following category list, you must include the total

Retirement benefits are paid to you on the same

amount of these benefits on Line 19.

check, write this amount on Line 13. Remember to

01 aged

include your Medicare deductions.

02 blind

14 Railroad Retirement benefits

03 disabled

Write the total amount of any retirement, disability,

04 temporary assistance to

}

or survivor’s benefits (including Medicare

06 needy families (TANF)

deductions) you and your spouse received in 2004

07 general assistance

under the Railroad Retirement Act.

It is not necessary to contact the Human Services

If you included your Railroad Retirement benefits

office to obtain the amount in cash payments

on Line 13, do not write on Line 14.

received. To determine the total amount of your

15 Civil Service benefits

benefits, multiply by 12 the amount of cash

Write the total amount of any retirement, disability,

benefits you received in any one month in 2004.

or survivor’s benefits you and your spouse

Adjust your figures if you did not receive 12 equal

received in 2004 under any Civil Service

payments during this period.

retirement plan.

Food stamps and medical assistance you may

16 Annuity benefits

have received are not considered income and

Write the total amount received as an annuity by

should not be added to your total income.

you and your spouse in 2004 from any annuity,

Governmental cash public assistance benefits also

endowment, life insurance contract, or similar

may be distributed by units of local government

contract or agreement.

such as municipalities, counties, etc.

17 Other pensions

If you received more than $55 per month of cash

a Write the total of the federally nontaxable

assistance in the aged, blind, and disabled

portion received by you and your spouse in

categories, your grant will be reduced (see Page 4).

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 13

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