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20 Wages, salaries, and tips from work

24 Other income or (loss)

Write the total amount of wages, salaries, and tips

Write any other income or loss not reported on

you received in 2004 from working and the total

Lines 13 through 23. For an explanation of other

amount your spouse received in 2004 from

income, see Page 12, “What is considered

working. Add these amounts for both you and

income?”. Write a loss in parentheses. For

your spouse, and write the total on Line 20.

example, a $700 loss should be written as (700).

You cannot use a net operating loss (NOL)

21 Interest and dividends received

carryover in figuring income.

Write the total amount of interest and dividends

you and your spouse received in 2004 from all

If you are claiming a loss,

sources, including any government sources.

you must attach proof of loss of

income — see Page 18.

You must include both taxable and nontaxable

amounts.

25 Total income

22 Net rental, farm, and business income

Add Lines 13 through 24 and write the total. If you

or (loss)

report any losses in Lines 22, 23, and 24,

Write the total net income or loss from rental,

remember the loss is a decrease to your income.

farm, and business sources, as reportable for

Do not include amounts on Lines 17a and 18a in

federal income tax purposes in 2004.

this total.

You cannot use a net operating loss (NOL)

26 If you rented out any part of your home to

carryover in figuring income.

someone else, complete Lines 26a and 26b.

Write a loss in parentheses. For example, a $700

You must also include the amount you

loss should be written as (700).

received as rent on Line 22.

If you are claiming a loss,

a Write the number of rooms in your home.

you must attach proof of loss of

If you were a homeowner or renter and rented

income — see Page 18.

out part of your home to someone else in

2004, you must write the total number of

23 Net capital gain or (loss)

rooms in your home.

Write any net capital gain or loss you and your

b Write the number of rooms you rented

spouse received in 2004.

to someone else.

If you report a net capital loss, it cannot exceed

If you were a homeowner or renter and rented

$3,000. If you are married, but not living with your

out part of your home to someone else in

spouse, and you are filing a federal income tax

2004, you must write the number of

return in your name only, your net capital loss

rooms you rented to someone else.

cannot exceed $1,500. Write a loss in

parentheses. For example, a $700 loss should be

If you rented part of your home to someone

written as (700).

else, we will figure your grant using a

proportionately reduced amount for your rent or

You cannot use a net capital loss carryover

property tax.

in figuring income.

If you are claiming a loss,

you must attach proof of loss of

income — see Page 18.

Step 4:

Does your total income allow you to file this application?

27 See if you qualify

If you wrote 2 in Box 27, then Line 25 must

be less than $28,480.

Write the number of persons you are reporting

If you wrote 3 (or more) in Box 27 then

on Form IL-1363 and on Schedule B, Qualified

Line 25 must be less than $35,740.

Additional Residents.

If yes, go to Step 5. If no, STOP. You still may

Compare Line 25 to Box 27 to determine if you

be eligible for drug coverage. See “Projecting

are eligible for these programs.

your income” on Page 15.

If you wrote 1 in Box 27, then Line 25 must

be less than $21,218.

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 14

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