Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to access the Circuit Breaker Application Form. This will allow you to open the form in your preferred online editor.
2. Begin with Section A, where you will provide your personal details. Fill in your birth date, Social Security number, full name, address, and phone number carefully to ensure accuracy.
3. Next, move to Section B if you are married and living with your spouse. Here, you will enter your spouse’s Social Security number, name, and birth date.
4. Proceed to Section C where you will detail both your and your spouse’s total income for the year. Make sure to include all relevant sources of income.
5. In Section D, you will determine if your total income qualifies you to file this application. You will be asked to assess your household size.
6. Continue to Section E to report any property taxes or rent you paid in the specified year. Be sure to include complete details to avoid delays.
7. If applicable, complete Section F for Illinois Cares Rx benefits. Indicate your citizenship status and answer questions about Medicare and HIV/AIDS.
8. If you are applying for your spouse’s Illinois Cares Rx benefits, fill out Section G with the required information about your spouse.
9. For additional Illinois Cares Rx benefits, complete Section H, which includes financial inquiries regarding savings and resources.
10. Section I is for those seeking the Ride Free Transit Card. Indicate your interest and complete any related information.
11. In Section J, provide your signature along with the date, confirming all information is correct. If applicable, have your spouse sign as well.
12. Once you have filled out all sections, review the form for accuracy before choosing to save your changes, download, print, or share the completed application.

Complete your Circuit Breaker Application Form online today for assistance you may qualify for.