Circuit Breaker Application Online Form PDF Details

For residents of Illinois seeking property tax relief or pharmaceutical assistance, the Amended Application for IL-1363 Benefits, IL-1363-X form, is a crucial document. This form is designed to amend previously filed applications for those who qualify under the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act. It starts by asking for personal details, including your social security number, name, address, and marital status, crucial for identifying the applicant. Furthermore, it extends to inquiring about your spouse's information if applicable, emphasizing the importance of accuracy in such sensitive data. The heart of the form lies in Section C, which meticulously asks for detailed income information from various sources, underscoring the need for applicants to report their financial status comprehensively. This includes everything from social security benefits and pensions to wages and net business income, highlighting the inclusive approach to understanding an applicant's financial situation. Subsequent sections require documentation on property tax, rent, or mobile home tax paid, reflecting the form's role in granting relief based on these expenses. Submission of this form, backed by required documentation, offers a pathway to potential financial relief for those grappling with property taxes or medication expenses, making it an essential tool for Illinois's senior and disabled residents. Carefully signing and submitting this document, along with adherence to guidelines for additional documents, can significantly influence the processing time and outcome of the application, emphasizing the form's importance in availing of the state's support programs.

QuestionAnswer
Form NameCircuit Breaker Application Online Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesil 1363 circuit breaker application, il form 1363, il 1363, il1363 form

Form Preview Example

State of Illinois

Illinois Department on Aging

20_ _ IL-1363-X

Amended Application for Form IL-1363 Beneits

Oficial use only

SECTION A: Tell us about yourself (claimant). Please print.

1 Social Security number 2 Name ___________________________________________

FirstMI Last

3 Address _______________________________ Apt. ______

City ______________________ State ____ ZIP __________

4 Phone ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

Area Code

5 Birth date

Month

Day

Year

6Marital status (only one box)

1 Single, widow(er), or divorced

2 Married/civil union and living together

3 Married/civil union, but not living together

7 Are you Male Female

SECTION B: Tell us about your spouse.

Complete this section if you checked Marital status 2.

8 Your spouse’s Social Security number. .............8

9 Your spouse’s name. .........................................9

Spouse includes parties to a civil union.

_______________________________________________

First

MI

Last

10 Your spouse’s birth date. ................................ 10

Month

Day

Year

SECTION C: Write only the claimant’s and spouse’s total income for 20_ _ .

You must include your spouse’s income (if married and living together).

11 Social Security, SSI beneits. Include Medicare deductions (yearly total)

 

 

 

11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12 Railroad Retirement beneits. Include Medicare deductions (yearly total)

 

 

 

12

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13 Civil Service beneits (yearly total)

 

 

 

 

 

 

 

 

 

 

 

 

13

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.................................................................................

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14 Annuity beneits (yearly total)

 

 

 

 

 

 

 

 

 

 

 

 

14

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15 Other pensions (yearly total)

 

 

 

 

 

 

 

 

 

 

 

 

 

15

 

 

 

 

 

 

 

 

 

......

 

b taxable

 

 

 

 

 

16 Veterans’ beneits (yearly total)

 

 

 

 

 

 

 

 

 

 

16

 

 

 

 

a nontaxable

 

 

 

 

 

.....

 

b taxable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17 Human Services and other cash public assistance beneits (yearly total)

 

 

 

17

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18 Wages, salaries, and tips from work (yearly total)

 

 

 

+

 

 

 

 

 

=

18

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claimant

 

 

 

Spouse

 

 

 

 

 

 

19 Interest and dividends received (yearly total)

 

 

 

 

 

 

 

 

19

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20 Net farm, business or rental income or (loss). If loss, attach copy of U.S. 1040

20

 

 

 

 

 

 

 

 

 

 

 

 

21 Net capital gain or (loss). If loss, attach copy of U.S. 1040 and Schedule D

 

 

 

21

 

 

 

 

 

 

 

 

 

 

 

..............

 

 

 

 

 

 

22 Other income, (loss) or (deductions). If loss or deductions, attach copy of U.S. 1040

22

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23 Add Lines 11 through 22. This is your total income.

 

 

 

 

 

23

 

 

 

 

 

 

 

 

 

 

 

 

 

-

---

----

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 Number of rooms in your home.

 

 

 

 

a _____________

 

Go to SECTION D

b Number of rooms you rented out to someone else.

b _____________

 

Form IL-1363-X (R-12/11) 1 of 4

SECTION D: Tell us how many persons you are reporting for the year for which you

are iling this amended application. (See instructions for more information.)

.......................

 

25 Household size (add the number of persons on Lines 2 and 9 and on Schedule B, Line 2)

SECTION E: Tell us about the Illinois property tax or rent you paid in the year

 

 

for which you are iling this amended application.

 

 

 

 

26 Property tax you paid or was payable in 2011 (total of both installments)

26

 

 

 

 

 

 

27Mobile home tax you paid (yearly total). .......................................................................27

28Rent you paid in 2011 (yearly total). Did your rent include food? yes F no F .....28 a To whom did you pay rent in 2011?

Name ____________________________________________ Phone ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

Address ______________________________________ City ____________________ State ____ ZIP ___________

b How many months did you rent here?b ____________ Attach page if other rentals.

Do not include amounts paid by a “Section 8” program. Do not include amounts you did not pay.

If you now live in public housing, but last year lived in private housing, see the instructions for Line 28. Failure to complete this section will delay the processing of your application.

29 Nursing, retirement, or shelter care home charges you paid (yearly total)

29

aTo whom did you pay nursing, retirement, or shelter care home charges?

Name ____________________________________________ Phone ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

Address ______________________________________ City ____________________ State ____ ZIP ___________

b How many months did you live here?

b ____________

Attach page if other rentals.

Do not include amounts paid by Human Services.

 

 

30Have you been claimed as a dependent on someone else’s tax return for the year you are amending? yes F no F

SECTION F: Sign below.

Under penalties of perjury, I state that I have examined this form and, to the best of my knowledge, it is true, correct, and complete. I give the

state of Illinois permission to get records from anyone concerning information on this form. As permitted by law, and subject to revocation, I authorize disclosure of the following information to, by, and between the Illinois Department on Aging and the Illinois Department of Healthcare and Family Services for the Circuit Breaker/Illinois Cares Rx Programs: (1) citizenship, identiication, and HIV/AIDS status information maintained by the Illinois Department of Public Health; (2) tax return information maintained by the Illinois Department of Revenue and the Internal Revenue Service (3) citizenship and identiication information maintained by the Illinois Secretary of State and the United States Citizenship and Immigration Services (USCIS); and (4) identiication information for ride programs offered by mass transit authorities, for the limited purposes of conirming my eligibility for applicable beneits and related outreach enrollment efforts through the end of the appropriate audit period. If resource availability permits, I also authorize the state of Illinois to apply on my behalf for any federal drug beneits I may be eligible to receive under the Medicare program. I assign to the state of Illinois my right to any beneits, including reimbursement, under

any private plan of assistance, public assistance program, insurance plan, or from any liable third party, for prescription drugs that I receive

through the Illinois Cares Rx program. I also agree that if I receive any such payments or other payments or beneits under the programs

on this form in error, or that I was not entitled to, I will repay them to the state of Illinois. I authorize release of medical and pharmaceutical

records for audit and veriication purposes, and exchange of health care information between any drug utilization review service authorized

by the state of Illinois and any of my physicians and pharmacists to the extent necessary for the operation of a drug utilization review service.

31

X

___/___/___ 33

___________________________ _____________

 

Claimant’s signature

Date

Preparer’s name (Please print or type.)

Phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32

X

___/___/___

 

Official use only

 

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse’s signature (If living together)

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SHAP

County/Sub-Area Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mail your completed form to:

Circuit Breaker, Illinois Department on Aging

P.O. Box 19003

Springield, Il 62794-9003

If you need assistance, 1) visit www.cbrx.il.gov on the Internet, 2) ind a local agency serving seniors by

calling the Senior HelpLine at 1-800-252-8966, or

3)call us at 1-800-624-2459 or 1-888-206-1327 (TTY).

IOCI 0853-11

2 of 4 Form IL-1363-X (R-12/11)

This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act. Disclosure of this information is REQUIRED. Failure to provide information could delay your grant and/or prescription coverage. IL-402-1098

Line-by-line instructions for Form IL-1363-X

Who should ile Form IL-1363-X?

You should ile Form IL-1363-X if you need to amend your Form IL-1363, Application for Circuit Breaker, for the years 2008, 2009, 2010 or 2011.

If you did not request drug coverage on your original Form IL-1363, and you or your spouse wish to apply for drug coverage, you must complete the form, ADAD-16, Application for Illinois Cares Rx. Illinois Cares Rx coverage may

ONLY be requested if you are amending a 2011 application.

How long does it take for processing?

Processing will take at least 12 weeks, so please be patient before calling us to check on the status of your amended application. Do not ile a duplicate amended application.

What if I need additional information or forms?

For information or to order forms, visit our Web site at www.cbrx.il.gov or call us at 1-800-624-2459 or our TTY at 1-888-206-1327. To ind a local agency serving seniors, call the Senior HelpLine at 1-800-252-8966.

LINE-BY-LINE INSTRUCTIONS

SECTION A: Tell us about yourself.

Lines 1 through 7

Complete with your current information.

SECTION B: Tell us about your spouse.

Complete Section B only if you checked Marital status 2, “Married/civil union and living together” on Line 6. Other- wise, if you do not have a spouse, if your spouse died be-

fore January 1, 2012, or if you were not living in the same household as your spouse in 2011, go to Section C.

Lines 8 through 10

Complete with your spouse’s current information.

SECTION C: Tell us your total income for the year for which you are iling this

amended application (include both claimant and spouse if living together).

Complete Section C using your correct income amounts. Place a zero on a line if you do not have any income to report. You must complete each line.

How to report a corrected amount:

If you reported $12,000 on Line 11 of your originally iled Form IL-1363, but now you have received an additional

statement showing you actually received $15,500, you need to ile Form IL-1363-X. You should complete Line 11 of Form IL-1363-X like this:

15,500

How to report an amount that did not change:

If you reported $1,000 on Line 12 of your original Form IL-1363, and the amount has not changed, you should complete Line 12 of Form IL-1363-X like this:

1,000

For each correction in Section C, you must send us the documentation listed below.

11 For any income correction, you must send us a copy of Form SSA-1099, Social Security Beneit State- ment, showing the amount in Social Security beneits

you received (including Medicare deductions) and/or

a statement from the Social Security Administration showing any Supplemental Security Income (SSI) you received.

12 For any income correction, you must send us written

proof from Railroad Retirement showing the amount in beneits you received (including Medicare deductions).

13 For any income correction, you must send us written

proof from Civil Service showing the amount in ben- eits you received.

14 For any income correction, you must send us a copy of your annual statement showing any income you received from an annuity, endowment, life insurance contract or similar contract or agreement.

15 For any income correction, you must send us a copy of your annual statement showing both your taxable and nontaxable income you received from any IRAs, IRAs converted to Roth IRAs, and pensions.

16 For any income correction, you must send us a copy

of your annual statement from the Veterans’ Adminis- tration showing both taxable and nontaxable beneits.

17 For any income correction, write the total amount of Il- linois Department of Human Services or other govern- mental cash public assistance beneits you received.

18 For any income correction, you must send us a copy of all of your W-2 forms (Wage and Tax Statement) furnished by all your employers and a copy of your federal income tax return and any supporting federal schedules.

19 For any income correction, you must send us a copy of your statements of interest and dividend income received from all sources.

20 For any income correction, you must send us a copy

of your federal income tax return and any supporting federal schedules. If you did not ile a federal return, you must attach other proof showing the nature and

amount of each change in income or loss.

Form IL-1363-X (R-12/11) 3 of 4

(Line-by-line instructions for Form IL-1363-X continued…)

21 For any income correction, you must send us a copy

of your federal income tax return and any supporting federal schedules. If you did not ile a federal return, you must attach other proof showing the nature and

amount of each change in income or loss.

22 For any income correction, you must send us a de- scription of the nature of the income, loss or deduction reported and attach written proof.

23 Add the amounts in Lines 11 through 22, and write the total on Line 23.

You cannot use a net capital loss carryover or a net operating loss carryover in iguring income.

24 If you rented out any part of your home to someone else, complete Lines 24a and 24b.

aWrite the total number of rooms in your home.

bWrite the number of rooms you rented out to someone else.

SECTION D: Tell us how many persons you

are reporting for the year for which you are iling this amended application.

25 Add the number of persons you are reporting on Form IL-1363-X, Lines 2 and 9, and on Schedule B, Quali- ied Additional Residents, Line 2.

If you are reporting any qualiied additional resi-

dents, you must attach Schedule B.

SECTION E: Tell us about the Illinois

property tax or rent you paid in the year for which you are iling this amended application.

26 For any correction, you must send us a copy of your property tax bill or a statement from your mortgage company showing the property tax you paid.

27 For any correction, you must send us a copy of your mobile home tax bill.

28 Check “yes” or “no” to indicate whether your rent included food. Also, for any other correction, you must send us a notarized statement from your landlord,

a copy of a rental agreement or lease, or cancelled checks showing the total amount in rent you paid. We will not accept rent receipts. Do not include the amount paid by a Section 8 program.

aWrite the name, address, and telephone number of your landlord. If you had more than one landlord, please attach additional sheets with the above infor- mation for each landlord. Please write your name and Social Security number on each attachment.

bWrite the number of months during which you rented from this landlord.

If you now live at a residence that is not sub- ject to property tax (such as public housing) but you did live at a residence that was subject to property

tax (such as private housing) during part or all of the year for which you are iling this amended application, you must send us a copy of your rental agreement

or lease, a notarized statement from your landlord, cancelled checks to document the rent you paid to the private landlord, or a copy of your tax bill. If you lived in more than one residence, you must also attach a letter stating the dates you lived at each residence.

29 For any correction, you must send us a copy of the statement from your nursing, retirement, or shelter care home showing the total amount you paid. See note below.

aWrite the name, address, and telephone number of the nursing, retirement, or shelter care home in which you lived.

bWrite the number of months during which you lived in this home.

If you lived in more than one home, please attach additional sheets with the Line 29, 29a, and 29b information for each place you lived. Please write your name and Social Security number on each attachment.

30If you were claimed as a dependent by someone else

on their tax return for the year you are amending, check “yes”; otherwise check “no”.

SECTION F: Sign below.

31 You (the claimant) must sign and date this form. See note below.

32 If you are married and living with your spouse, your spouse must sign and date Form IL-1363-X.

If you or your spouse is only able to make a mark, another person must sign as a witness. If you or your spouse is unable to sign, a legal representative may sign this form. However, you must attach docu- mentation proving that the representative is a legal guardian or has power of attorney to act for you or your spouse. Applications without a valid signature or mark will not be approved.

33 Write the preparer’s name and phone number on this form. If someone other than you or your spouse, such as a son, daughter, or legal representative, prepares this form for you, that person should print or type his or her name and telephone number on Line 33.

Form IL-1363-X (R-12/11) 4 of 4

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il 1363 circuit breaker application conclusion process described (step 1)

2. The subsequent part would be to fill in these blanks: SECTION C Write only the claimants, Social Security SSI beneits, Claimant, Spouse, Net farm business or rental, Net capital gain or loss If loss, Other income loss or deductions, Add Lines through This is your, Do not include Lines a and a in, If you rented out any part of, a Number of rooms in your home b, and Go to SECTION D.

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3. In this particular step, take a look at SECTION D Tell us how many persons, Household size add the number of, SECTION E Tell us about the, a To whom did you pay rent in, Address City State ZIP, b How many months did you rent here, Do not include amounts paid by a, Attach page if other rentals, Nursing retirement or shelter, a To whom did you pay nursing, and Address City State ZIP. Each one of these must be filled in with greatest awareness of detail.

Tips to fill out il 1363 circuit breaker application stage 3

4. This fourth paragraph arrives with the following fields to consider: Do not include amounts paid by, b How many months did you live here, Have you been claimed as a, yes F no F, Attach page if other rentals, SECTION F Sign below Under, Preparers name Please print or type, X Claimants signature, Phone number, and Date.

Find out how to fill in il 1363 circuit breaker application stage 4

5. And finally, this final part is what you have to complete before finalizing the PDF. The blank fields you're looking at are the following: X Spouses signature If living, Date, Official use only, SHAP CountySubArea Code, Mail your completed form to, If you need assistance visit, IOCI of Form ILX R, and This form is authorized as.

il 1363 circuit breaker application conclusion process clarified (part 5)

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