Form Il-1363 - Application For Circuit Breaker Grant, License Plate Discount, And Optional Help Paying For Drugs (Pharmaceutical Assistance Or Seniorcare) - 2004 Page 3
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20Who should apply? (
)
continued
If my spouse died before applying, do
If you were 63 or 64 years of age before the
death of your spouse and your spouse was
I qualify?
receiving or was eligible to receive
If your spouse died in 2004 or 2005 before
Form IL-1363 benefits,
sending us a properly completed 2004
you must also attach proof of
Form IL-1363, you may qualify. You must meet
death — see Page 17.
the requirements listed under “Who should
apply?” on Page 2.
What if I share my home with
You must complete Form IL-1363 in your own
someone other than my spouse or
name. Be sure to read the instructions for
any qualified additional resident?
Line 7 on Page 11 to determine the correct box
to check for your situation.
A person who lives with you (other than your
You must include the amount of income your
spouse or qualified additional resident) may
spouse received during the months your
apply on a separate Form IL-1363, if he or she
spouse was living with you in 2004.
meets the requirements listed under “Who
should apply?” on Page 2.
You must attach proof of your age
— see Page 17.
How do I apply?
Your 2004 Form IL-1363, Application, must be
Do I qualify to file on the internet?
postmarked on or before December 31, 2005.
You may file your Form IL-1363 on the
internet, if
To get your benefits quickly,
you filed Form IL-1363 last year and were
complete your Form IL-1363 as soon as you have
approved;
the necessary information, and
your marital status did not change; and
file your completed application with us on the
internet (if you qualify) at ,
you are not required to send any
attachment, including Schedules A, B, or P.
or
send your completed application with any required
We can process applications filed on the internet
attachment to us as soon as possible.
faster than those we receive in the mail.
Confidentiality and privacy information
The information you disclose on this application is
If you do not have this type of documentation and
protected information under federal privacy and
you want someone else to contact us about your
state confidentiality laws. You can find the
Pharmaceutical Assistance application or benefits,
Pharmaceutical Assistance Program Privacy
you must call us or send us a completed
Notice about health information on our Website at
Form ADAD-PN3, Authorization for Use or
.
Disclosure of Medical Information.
You may contact us or get Form ADAD-PN3, if you
If you want someone else to contact us about your
Form IL-1363 application or benefits, you must
call
1 800 624-2459 8 a.m. to 5 p.m. weekdays
send us a copy of documentation to show that the
person is your legal guardian or has the
1 800 544-5304 TTY
appropriate power of attorney to act for you on
visit
such issues.
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Apply every year
Renew by March 31
IL-1363 instructions (R-12/04)
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