Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, And Optional Help Paying For Drugs (Pharmaceutical Assistance Or Seniorcare) - 2004 Page 18
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20You may need to attach...
Please write your name and Social Security number on each attachment.
Proof of your qualified additional
If you own your home —
attach a copy of your property tax bill or mobile
resident (Schedule B)
home tax bill, receipts from your county government,
If you are reporting qualified additional residents, you
or canceled checks documenting the property tax or
must complete and attach Schedule B, Qualified
mobile home tax you paid in 2004.
Additional Residents. You must attach proof of that
In addition —
person’s age. If you are applying for Pharmaceutical
attach the following information to explain how you
Assistance for your qualified additional resident who
are able to pay high rent, property tax, or mobile
is younger than 65 years of age, you must attach
home tax on a limited income. On a separate sheet
proof of his or her disability.
of paper, tell us
Your spouse is not a qualified additional resident.
whether family or friends helped pay your
rent, property tax, or mobile home tax and the
Proof of taxable and nontaxable
amount they paid on your behalf. (List only the
amount you paid on Line 30.)
benefits for Lines 17 and 18
whether your rent was subsidized and the
If you received pensions and/or veterans’ benefits
amount that was paid on your behalf. (List only
that are nontaxable and you want to help prevent
the amount you paid on Line 30.)
delays in receiving your Circuit Breaker grant or drug
whether you receive reverse mortgage
coverage, you must send us a copy of each of your
payments and the amount paid to you. (These
annual statements showing both taxable and
types of benefits are not considered income
nontaxable benefits.
and should not be reported in Step 3.)
whether other expenses were included in your
Proof of a loss of income
rent; for example, electric bills. (If your rent
If you are claiming a loss of income on Lines 22, 23,
included food, check “yes” on Line 30.)
or 24, you must attach a copy of your federal income
your portion of rent, property tax, or mobile
tax return as proof of any loss you report. If you did
home tax, if you shared your home with
not file a federal income tax return, you must send
someone other than your spouse or any
us a detailed explanation of the loss and how you
qualified additional resident. (If anyone else
figured it.
lived with you and paid you rent in 2004, write
the amount you received in rental income on
Proof of rent, property tax, or
Line 22 and complete Lines 26a and 26b.)
mobile home tax you paid
any information about minor dependent children
receiving Social Security, SSI, or child support.
If your income on Line 25 is less than or close to the
(These types of benefits are not considered
amount you paid in rent, property tax, or mobile
income and should not be reported in Step 3.)
home tax and you want to help prevent delays in
any other information to explain how you are
receiving your Circuit Breaker grant or drug
able to pay high rent, property tax, or mobile
coverage, send us the following:
home tax on a limited income.
If you are a renter —
attach a copy of your rental or lease agreement, a
Proof of authorized
notarized statement from your landlord, or canceled
representation for signature
checks documenting the rent you paid in 2004.
If someone must sign for you, you must attach
If you rented or leased the land on which your
proof that the person signing for you is your legal
mobile home is located —
guardian or has power of attorney to act for you.
attach a copy of your rental or lease agreement, a
If someone must sign for your spouse, you must
notarized statement from the land owner, or
attach proof that the person signing for your
canceled checks documenting the amount you paid
spouse is your spouse’s legal guardian or has
in 2004.
power of attorney to act for your spouse.
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Apply every year
Renew by March 31
IL-1363 instructions (R-12/04)
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Parent category: Financial