Circuit Breaker Application Online Form – Fill Out and Use This PDF

State of Illinois

Illinois Department on Aging

20_ _ IL-1363-X

Amended Application for Form IL-1363 Beneits

Oficial use only

1 Social Security number 2 Name ___________________________________________

FirstMI Last

3 Address _______________________________ Apt. ______

City ______________________ State ____ ZIP __________

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

Area Code

5 Birth date

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.

_______________________________________________

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

Month

Day

Year

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

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

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.