Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, And Optional Help Paying For Drugs (Pharmaceutical Assistance Or Seniorcare) - 2004 Page 17
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20You may need to attach...
Please write your name and Social Security number on each attachment.
Proof of your disability
Proof of age
If you are the claimant or spouse or qualified
If you are 16 years of age or older and totally
disabled, but younger than 65 years of age before
additional resident and you are applying for the
January 1, 2005, and you are the
first time, you must attach a copy of one of the
following examples as proof of age.
claimant, or
baptismal record
spouse or qualified additional resident who is
applying for Pharmaceutical Assistance
birth certificate
coverage,
driver’s license
you must attach one of the following as proof of
ID card from the Illinois Secretary of State
disability.
insurance policy
If you received Social Security disability benefits
passport
(and you did not file an approved Form IL-1363 last
year), you must send us one of the following:
If you have not filed an approved
Form IL-1363 since 2001, you are considered a
a copy of Form SSA-1099 showing a Medicare
first-time applicant.
deduction
a copy of your statement showing SSI benefits
Proof of death
a copy of your statement showing a Medicare
If you are a widow or widower who was 63 or 64
deduction
years of age before the death of your spouse (if
If you received Veterans Administration disability
your spouse was receiving or was eligible to
benefits, you must send us one of the following:
receive Form IL-1363 benefits and you do not
qualify as disabled), you must attach a copy of
a copy of your pension statement
your spouse’s death certificate and proof of your
a copy of your statement showing
age.
compensation rated at 100 percent
If you received Railroad Retirement or Civil
Proof of qualified noncitizen
Service disability benefits, you must send us
status
a copy of your pension statement from the
If you checked the “qualified noncitizen” box in
Railroad Retirement or Civil Service agency
Line 5b (Line 12b for your spouse), and you (or your
stating that you were totally disabled or you had
spouse) currently do not have a SeniorCare blue
a deduction for Medicare.
card, you must attach a copy of one of the following
If you had a Class 2 disability card from the
examples as proof of qualified noncitizen status:
Illinois Secretary of State’s office, you must send
Alien Registration Receipt Card (I-151 or I-551)
us
a copy of your Class 2 disability card as proof
Memorandum of Creation of Record of Lawful
of your disability.
Permanent Residence (I-181a)
If you did not receive any of the above items, you
Arrival-Departure Record (I-94)
must send us
other Immigration & Naturalization Services (INS)
a completed Schedule A, Physician’s Statement.
documents
(Use a separate Schedule A for each person.)
U.S. military discharge papers or current orders
If you are disabled and become 65 years old
(DD Form 2)
during 2005, we will prorate your grant and your drug
coverage will become effective on or after your
birthday unless you send us proof of your disability.
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Apply every year
Renew by March 31
IL-1363 instructions (R-12/04)
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