State of Illinois Application for DO NOT VALIDATE

Illinois Department on Aging

Circuit Breaker Illinois Cares Rx
License Plate Discount People with 113533670205
2010 IL-1363 Disabilities Ride Free Transit card Official use only

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

1 Social Security number 2 2 5 4 4 7 0 1 6 5 Birth date 1 0 0 6 1 9 3 5

Month Day Year
RONNIE L PERRY
2 Name ____________________________________________ 6 Marital status (
only one box)
First MI Last
205 S MAIN ST
3 Address _______________________________ Apt. _______ 1 Single, widow(er), or divorced
ZEIGLER
City ______________________ 62999-1123
IL ZIP ___________
State ____

X 2 Married and living together
3 Married, but not living together
6
4 Phone ( ___ 1
___ 8
___ 5
) ___ 9
___ 6
___ 6
- ___ 6
___ 6
___ 0
___ 7 Are you
X Male Female
Area Code

SECTION B: Tell us about your spouse (husband or wife).

Complete this section if you checked Marital status 2.

8 Write your spouses Social Security number. ......8. 3 2 9 6 6 1 2 8 0

MICHELLE D PERRY
9 Write your spouses name. ..................................9 _______________________________________________
First MI Last

10 Write your spouses birth date. ......................... 10. 0 3 1 2 1 9 6 9

Month Day Year

SECTION C: Write only the claimants and spouses total income for 2010. (See instructions)
You must include your spouses income (if married and living together).
12,366 00
11 Social Security, SSI benefits. Include Medicare deductions (yearly total)...................... 11
12 Railroad Retirement benefits. Include Medicare deductions (yearly total)...................... 12 0 00
0 00
13 Civil Service benefits (yearly total).................................................................................. 13
14 Annuity benefits (yearly total).......................................................................................... 14 0 00
0 00 0 00
15 Other pensions (yearly total)................... a nontaxable. ....... b taxable 15
0 00 21,529 00
16 Veterans benefits (yearly total)............... a nontaxable ...... b taxable 16
17 Human Services and other cash public assistance benefits (yearly total)...................... 17 0 00
0 00 0 00 0 00

18 Wages, salaries, and tips from work (yearly total) Claimant
+
Spouse
= 18
0 00
19 Interest and dividends received (yearly total)................................................................. 19
0 00
20 Net farm, business or rental income or (loss). If loss, attach copy of U.S. 1040........... 20
0 00
21 Net capital gain or (loss). If loss, attach copy of U.S. 1040 and Schedule D............... 21
0 00
22 Other income, (loss) or (deductions). If loss or deductions, attach copy of U.S. 1040... 22
33,895 00
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 Write the number of rooms in your home. a _____________ 0
0
b Write the number of rooms you rented to someone else. b _____________
Postmark deadline for filing is December 31, 2011. IL-1363 1 of 4 (R-12/10)
SECTION D: Does your total income allow you to file this application? (See instructions)
25 Write household size (add the number of persons on Lines 2 and 9, and on Schedule B). ................... 25 3

SECTION E: For your Circuit Breaker Grant.

Tell us about the Illinois property tax or rent you paid in 2010. (See instructions)
122 00
26 Property tax you paid or was payable in 2010 (total of both installments). ................. 26
0 00
27 Mobile home tax you paid in 2010 (yearly total). ........................................................... 27
0 00
28 Rent you paid in 2010 (yearly total). Did your rent include food? yes F no F ..... 28
Failure to complete the following information will delay the processing of your application.
a To whom did you pay rent in 2010?
Name _____________________________________________ Phone ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

Address ______________________________________ City ____________________ State ____ ZIP ____________

b How many months did you rent here in 2010? b _____________ Attach page if other rentals.
Do not include amounts paid by a Section 8 program.
If you now live in public housing, but last year lived in private housing, see the instructions for Line 28.
0 00
29 Nursing, retirement, or shelter care home charges you paid in 2010 (yearly total)........ 29
a To whom did you pay nursing, retirement, or shelter care home charges in 2010?
Name _____________________________________________ Phone ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

Address ______________________________________ City ____________________ State ____ ZIP ____________

b How many months did you rent here in 2010? b _____________ Attach page if other rentals.
Do not include amounts paid by Human Services.

Sections F, G and H should only be filled out if you are requesting Illinois Cares Rx
benefits or the monthly rebate. (If no, go to Section I.)

SECTION F: For your Illinois Cares Rx benefits or monthly rebate. (See instructions)
30 Are you a
U.S. citizen or
qualified noncitizen?
You may still get some drug coverage, a grant, a License Plate discount and/or Transit Card (if requested)
even if no box is checked above. You can either get help paying for prescriptions or instead you can get
a $25 monthly rebate.
31 Illinois Cares Rx Benefits. You can choose help paying for prescriptions.

a Do you have Medicare? yes F no F (If no, go to Line 32.)

b Do you have HIV/AIDS? yes F no F (See instructions for additional benefits.)
32 Monthly Rebate. You can choose to receive a $25 monthly rebate instead of help paying for prescriptions.
a Do you have private insurance that pays for your prescription drugs; or do you have Veterans Administration
(VA) benefits; or are you enrolled in a Medicare Part D plan that does not coordinate with Illinois Cares
Rx? (See Coordinating Plans, pages 12-13.)
yes F no F (If no, go to Section G.)

b Do you want a $25 monthly rebate instead of help paying for prescriptions? yes no F F
Do not mark yes if you are receiving prescriptions through a coordinating Illinois Cares Rx Medicare
Part D plan. If you are enrolled in one of these plans, Illinois Cares Rx will help pay for your prescriptions.
IL-1363 2 of 4 (R-12/10)
SECTION G: For your spouses Illinois Cares Rx benefits or monthly rebate. (See instructions)

33 Is your spouse a U.S. citizen or qualified noncitizen?

Your spouse may still get some drug coverage and/or a Transit Card (if requested) even if no box is
checked above. You can either get help paying for prescriptions or instead you can get a $25 monthly
rebate.

34 Illinois Cares Rx Benefits. Your spouse can choose help paying for prescriptions.
a Does your spouse have Medicare? yes F no F (If no, go to Line 35.)
b Does your spouse have HIV/AIDS? yes F no F (See instructions for additional benefits.)

35 Monthly Rebate. Your spouse can choose to receive a $25 monthly rebate instead of help paying
for prescriptions.
a Does your spouse have private insurance that pays for prescription drugs; or does your spouse have
Veterans Administration (VA) benefits; or is your spouse enrolled in a Medicare Part D plan that does not
coordinate with Illinois Cares Rx? (See Coordinating Plans, pages 12-13).
yes F no F (If no, go to Section H.)
b Does your spouse want a $25 monthly rebate instead of help paying for prescriptions? yes F
no F
Do not mark yes if your spouse is receiving prescriptions through a coordinating Illinois Cares Rx
Medicare Part D plan. If your spouse is enrolled in one of these plans, Illinois Cares Rx will help pay
for his or her prescriptions.

SECTION H: Additional information required for Illinois Cares Rx benefits or

monthly rebate. (See instructions)
Failure to complete this section will delay the processing of your application.

36 If you are married and living with your spouse, do you have savings, investments or real estate worth more
than $25,010? If you are not married or you do not live with your spouse, is the value more than $12,510?
Do NOT count the home you live in, vehicles, personal possessions, burial plots, irrevocable burial

contracts or back payments from Social Security or SSI.
yes
F no F
If you marked NO, you must complete Schedule C.

SECTION I: For People with Disabilities Ride Free Transit Card. (See instructions)
Complete this section if you or your spouse want to apply for or renew the People with Disabilities Ride Free Transit
Card and you are under 65 years of age. You must file an IL-1363 application each year and request a card every
year.

37 Yes, I want to apply for the Transit Card.

38 Yes, my spouse wants to apply for the Transit Card.

IL-1363 3 of 4 (R-12/10)
SECTION J: Sign below. (Attach proof of authority if someone else signs for you or your spouse.)

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, identification, 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
identification information maintained by the Illinois Secretary of State and the United States Citizenship
and Immigration Services (USCIS); and (4) identification information for ride programs offered by mass
transit authorities, for the limited purposes of confirming my eligibility for applicable benefits 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 benefits I may be eligible
to receive under the Medicare program. I assign to the state of Illinois my right to any benefits, 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 benefits 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 verification 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.

CBC11353306665
39 __X_____________________________ _ ___/___/___ 41 ____________________________ _____________
Claimants signature Date Preparers name (Please print or type.) Phone number

40 __X_____________________________ _ ___/___/___
Spouses signature (If living together) Date

Official use only

_
SHAP County/Sub-Area Code

Remember to notify us if you move to a new address after you apply for
benefits. Call us at 1-800-624-2459 or 1-888-206-1327 (TTY).

As a result of Public Act 096-0491, a fee cannot be charged to assist an

individual to complete an application form for Circuit Breaker/Illinois Cares Rx.

Postmark deadline for filing is December 31, 2011.

If applying for ALL Form IL-1363 benefits, including If ONLY applying for a grant, License Plate discount
Illinois Cares Rx, mail to: and/or the Transit Card, mail to:
CIRCUIT BREAKER/ILLINOIS CARES RX CIRCUIT BREAKER
ILLINOIS DEPARTMENT ON AGING ILLINOIS DEPARTMENT ON AGING
P.O. BOX 19021 P.O. BOX 19003
SPRINGFIELD, IL 62794-9021 SPRINGFIELD, IL 62794-9003

If you need assistance, 1) visit www.cbrx.il.gov, 2) find 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 0214-11 This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act.
IL-1363 4 of 4 (R-12/10) Disclosure of this information is REQUIRED. Failure to provide information could delay your grant and/or prescription coverage. IL-402-1093
 State of Illinois, Department on Aging

2010 Schedule B Qualified Additional Resident (QAR)

Attach to claimants Form IL1363. (A separate Schedule B must be completed for each QAR.)

Who is a qualified additional resident?

A qualified additional resident is an individual, other than your spouse,
who lived with you in the same residence in 2010 and in 2011 at the time you file your 2010 Form IL-1363; and
for whom you, or you and your spouse, provided more than half of that persons total financial support in 2010; and
who is not filing a separate 2010 Form IL-1363.

STEP 1: Tell us about your qualified additional resident. Please print.

1 Social Security number 3 4 9 9 8 2 3 6 3
JACOB T PERRY
2 Name _________________________________________________________________________________
First MI Last

3 Birth date

1 1 2 0 2 0 0 1
Month Day Year
4 Check if requesting Illinois Cares Rx drug coverage.
Attach proof of age (first-time filer). If the person listed in Line 2 is younger than 65 years of age
and the box in Line 4 is checked, attach proof of disability.

For your QARs Illinois Cares Rx benefits or monthly rebate. (See instructions)
5 Is your QAR a
U.S. citizen or qualified noncitizen?
Your QAR can either get help paying for prescriptions or instead your QAR can get a $25 monthly rebate.
6 Illinois Cares Rx Benefits. Your QAR can choose help paying for prescriptions.
a Does your QAR have Medicare? yes no F F
b Does your QAR have HIV/AIDS? yes no F F
7 Monthly Rebate. Your QAR can choose to receive a $25 monthly rebate instead of help paying for prescriptions.
a Does your QAR have private insurance that pays for prescription drugs; or does your QAR have Veterans
Administration (VA) benefits; or is your QAR enrolled in a Medicare Part D plan that does not coordinate
with Illinois Cares Rx? yes no F F
b Does your QAR want a $25 monthly rebate instead of help paying for prescriptions? yes no F F
Do not mark yes if receiving prescriptions through a coordinating Illinois Cares Rx Medicare Part D
plan. If your QAR is enrolled in one of these plans, Illinois Cares Rx will help pay for their prescriptions.

STEP 2: Claimant sign below.

Under penalties of perjury, I certify that the individual listed in Step 1 is a qualified additional resident for whom I, or my spouse and I, provided more than half
of their total financial support in 2010, and that this individual lived with me in the same residence in 2010 and in 2011 at the time I filed my 2010 Form IL-1363.

8 ________________________________________ ____/___/___ 9 2 2 5 4 4 7 0 1 6

Claimants signature Date Claimants Social Security number

STEP 3: QAR sign below. (Attach proof of authority if someone else signs for you.)

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, identification, 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 identification information maintained by the Illinois Secretary of State and the
United States Citizenship and Immigration Services (USCIS); and (4) identification information for ride programs offered by mass transit authorities, for the limited
purposes of confirming my eligibility for applicable benefits 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 benefits I may be eligible to receive under the Medicare program.
I assign to the state of Illinois my right to any benefits, 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 benefits 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 verification 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.

10 _____________________________ ___/___/___ _11_____________________________ ___/___/___

Signature of person named on Line 2 (QAR) Date Signature of Authorized Representative for the QAR Date
(If younger than 18, see instructions.)