Form Il-1363 - Application For ,circuit Breaker ,illinois Cares Rx ,license Plate Discount - 2009
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Application for
State of Illinois
·
Circuit Breaker
Illinois Department on Aging
·
Illinois Cares Rx
2009 IL-1363
·
License Plate Discount
Official use only
A
SECTION
:
Tell us about yourself (claimant).
Please print.
1
5
Social Security number
Birth date
Month
Day
Year
2
6
Name
____________________________________________
Marital status (
only one box)
First
MI
Last
Single, widow(er), or divorced
1
3
Address
_______________________________
Apt.
_______
Married and living together
2
Married, but not living together
City
______________________
State
____
ZIP
___________
3
4
7
Phone
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Are you
Male
Female
Area Code
B
SECTION
:
Tell us about your spouse (husband or wife).
Complete this section if you checked Marital status 2.
8
8
Write your spouse’s Social Security number. ....
9
9
Print your spouse’s name. .................................
_____________________________________________
First
MI
Last
10
10
Write your spouse’s birth date. ........................
Month
Day
Year
C
SECTION
:
Write only the claimant’s and spouse’s total income for 2009.
You must include your spouse’s income (if married and living together).
11
11
Social Security, SSI benefits. Include Medicare deductions (yearly total) ....................
12
12
Railroad Retirement benefits. Include Medicare deductions (yearly total) ...................
13
13
Civil Service benefits (yearly total) ...............................................................................
14
14
Annuity benefits (yearly total) .......................................................................................
15
15
Other pensions (yearly total)................. a nontaxable
..... b taxable
16
16
Veterans’ benefits (yearly total) ............ a nontaxable
..... b taxable
17
17
Human Services and other cash public assistance benefits (yearly total) ....................
$0.00
18
18
Wages, salaries, and tips from work (yearly total)
+
=
Claimant
Spouse
19
19
Interest and dividends received (yearly total) ...............................................................
20
20
Net farm, business or rental income or (loss). If loss, attach copy of U.S. 1040. ........
21
21
Net capital gain or (loss). If loss, attach copy of U.S. 1040 and Schedule D. ............
22
22
Other income, (loss) or (deductions). If loss or deductions, attach copy of U.S. 1040.
$0.00
- - - - - - - - - - - - -
23
This is your total income.
23
Add Lines 11 through 22.
Do not include Lines 15a and 16a in your total.
24
If you rented out any part of your home to someone else, complete Lines 24a and 24b.
_____________
a Write the number of rooms in your home.
a
_____________
b Write the number of rooms you rented to someone else.
b
Postmark deadline for filing is December 31, 2010.
IL-1363 1 of 4 (R-12/09)
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