Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, And Optional Help Paying For Drugs (Pharmaceutical Assistance Or Seniorcare) - 2004 Page 16
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20but during part or all of 2004 lived at a residence
include amounts paid to the home by the Illinois
that was subject to property tax (such as private
Department of Human Services, any medical
housing),
assistance programs, or your insurance
company.
you must attach a copy of your
property tax bill, rental agreement, lease,
31a To whom did you pay nursing, retirement,
notarized statement from your landlord, or
or shelter care home charges in 2004?
canceled checks to document the rent you
Write the name, address, and telephone
paid to a private landlord. Also, send us a
number of the nursing, retirement, or
letter stating the dates you lived at each
shelter care home to whom you paid these
residence.
charges.
31
Nursing, retirement, or shelter care home
31b How many months did you live here in
2004?
charges you paid in 2004
Write the number of months during which
Complete Line 31 only if you consider the
you lived in this home.
nursing, retirement, or shelter care home as your
principal or permanent residence. Write the total
amount in charges you paid in 2004. Do not
Step 6:
Sign below.
Signature statement
are unable to sign, your legal representative
may sign for you; however,
Under penalties of perjury, I state that I have
you must send us proof that the person
examined this form and, to the best of my knowledge,
signing for you is your legal
it is true, correct, and complete. I give the state of
guardian or has power of attorney to
Illinois permission to get records from anyone
act for you — see Page 18.
concerning information on this form. I authorize the
Applications without a valid signature or mark
Illinois Department of Revenue to disclose
will not be approved.
information from any of my tax returns for the limited
purpose of confirming my eligibility for benefits. I also
If the claimant is not yet age 18, the
assign to the state of Illinois my right to any benefits,
claimant’s parent or guardian must sign on
including reimbursement, under any private plan of
Line 32, indicating the relationship to the
assistance, public assistance program, insurance
claimant (such as “mother,” “father,” or
plan, or from any liable third party, for prescription
“guardian”).
drugs that I receive through the Circuit Breaker
33 Spouse’s signature
Pharmaceutical Assistance programs or SeniorCare.
I also agree that if I receive any such payments or
If you are married and living with your spouse,
other payments or benefits under these programs in
your spouse must sign and date Form IL-1363
error, or that I was not entitled to, I will repay them to
on Line 33. If your spouse is able only to make a
the state of Illinois. I authorize release of medical and
mark, another person must sign as a witness. If
pharmaceutical records for audit and verification
your spouse is unable to sign, your spouse’s
purposes, and exchange of health care information
legal representative may sign; however,
between any drug utilization review service
you must send us proof that the person
authorized by the state of Illinois and any of my
signing for your spouse is his or her
physicians and pharmacists to the extent necessary
legal guardian or has power of attorney
for the operation of a drug utilization review service.
to act for your spouse — see Page 18.
32 Your (the claimant’s) signature
34 Preparer’s name
You must sign and date the application on
If someone other than you or your spouse, such
Line 32. If you are only able to make a mark,
as a son, daughter, or legal representative,
another person must sign as a witness. If you
prepares this form for you, that person should
print or type his or her name and telephone
number on Line 34.
16
Apply every year
Renew by March 31
IL-1363 instructions (R-12/04)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, Ride Free Transit Card, Illinois Cares Rx - 2010
Legal
Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, Ride Free Transit Card, Illinois Cares Rx - 2011
Medical
Form Il-1363 - Application For Circuit Breaker / Illinois Cares Rx / License Plate Discount - 2008
Legal
Related Categories
Parent category: Financial