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Who should apply?

Apply on Form IL-1363 if you meet the following

Who qualifies as disabled?

requirements for age, residency, and income:

To qualify as disabled, you must be at least

1 Age

16 years of age and

you must be 65 years of age or older before

receive disability benefits from one of the

January 1, 2005; or

following:

you must become 65 years of age during 2005

1 Social Security Administration, or

(benefits become available after you turn 65; your

2 Veterans Administration, or

Circuit Breaker grant will be prorated based on

3 Civil Service, or

the number of months you were 65); or

4 Railroad Retirement,

you must be 16 years of age or older before

or have one of the following:

January 1, 2005, and totally disabled; or

5 a Class 2 disability card from the Illinois

you must be a widow or widower who was 63 or

Secretary of State’s office, or

64 years of age before the death of your spouse

6 a completed Schedule A, Physician’s

(if your spouse was receiving or was eligible to

Statement, if you are not yet age 65 and do

receive Form IL-1363 benefits).

not have other proof of disability as listed

2 Residency

above. Schedule A must show that you were

you must live in Illinois at the time you file your

totally and permanently disabled in 2004.

application; and

Note: Use a separate Schedule A for each

(this requirement is only for SeniorCare) you

person who is not yet age 65 and needs to

must continue to be a resident of Illinois; and

send us other proof of disability.

(this requirement is only for a Circuit Breaker

You must attach proof of disability

grant) you must have lived in an Illinois residence

— see Page 17.

in 2004 that was subject to property or mobile

home tax.

Who is a qualified additional

3 Income

resident?

Your* total income (see Page 12) in 2004** must be

A qualified additional resident is an individual,

less than

other than your spouse,

$21,218 if filing an application for yourself only;

who lived with you in the same residence in

2004 and in 2005 at the time you file your

$28,480 if filing an application for yourself and

2004 Form IL-1363; and

your spouse*, or yourself and one qualified

for whom you, or you and your spouse,

additional resident; or

provided more than half of that person’s total

$35,740 if filing an application for yourself, your

financial support in 2004; and

spouse*, and at least one qualified additional

who is not filing a separate 2004 Form IL-1363.

resident, or yourself and at least two qualified

additional residents.

You must attach proof of your qualified

additional resident (Schedule B) — see

* If your spouse lived with you, you must add

Page 18.

your spouse’s income to your income.

** If your 2004 income was over these limits, but

What if I am married?

you have experienced a decrease in your

If you are married and you and your spouse lived

income, you may qualify for prescription

together during 2004, you must complete one

coverage. See “Projecting your income” in the

Form IL-1363 and report your total combined

instructions for Step 4 on Page 15.

income. Your spouse cannot apply separately.

What if I am not a U.S. citizen?

If one or both of you lived in a nursing home, you

You do not have to be a U.S. citizen to qualify for

should each complete separate Forms IL-1363.

a Circuit Breaker grant, license plate discount, or

If you and your spouse were permanently

help paying for your drugs. If you are 65 years old

separated in 2004 and are still living at different

or older, you may qualify for SeniorCare instead

addresses, you may each complete separate

of Pharmaceutical Assistance — see “SeniorCare

Forms IL-1363.

requirements for noncitizens” on Page 7.

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 2

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