Form Ptax-343-R - Annual Verification Of Eligibility For The Homestead Exemption For Persons With Disabilities (Hepd) - 2015
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PTAX-343-R
Annual Verification of Eligibility for the Homestead
Exemption for Persons with Disabilities (HEPD)
Last date to apply: ___ ___/___ ___/___ ___ ___ ___
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Read this first
To continue to receive the HEPD, you must file Form PTAX-343-R each year with your Chief County Assessment Officer (CCAO) by your
county’s due date. Failure to do so may result in the termination of the exemption.
Step 1:
Complete the following information
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___ ___/___ ___/___ ___ ___ ___
Your date of birth:
Property owner’s name
3
Assessment year for which you are requesting this
________________________________________________
___ ___ ___ ___
exemption:
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Street address of homestead property
Year
IL
4
Enter the property index number (PIN) of the property for which
________________________________________________
City
State
ZIP
you receive the exemption listed on your property tax bill. You
may obtain it from your CCAO. If you are unable to obtain your
PIN, attach a copy of the legal description.
(_____)______-___________ _______________________
Daytime phone
Email address
a PIN _________________________________________
Step 2:
Complete your affidavit
Part 1: Check either “yes” or “no” as it applies to the property and assessment year you identified in Step 1.
5 Is this the only property for which you have applied for this exemption
?
Yes
No
6 On January 1, were you the owner of record, or have a legal or equitable interest,
or have a life care contract with a facility under the Life Care Facilities Act
?
Yes
No
7
Are you liable for the payment of real estate taxes?
Yes
No
8
On January 1, did you occupy this property as your primary residence?
Yes
No
9
/DD (intellectually disabled/developmentally
On January 1, were you a resident of a facility licensed under the ID
disabled) Community Care Act,
Nursing Home Care Act, Specialized Mental Health Rehabilitation Act of 2013, or MC/DD
(Medically Complex for the Developmentally Disabled) Act?
Yes
No
If Yes,
a
enter the name and address of the facility.
_____________________________________________
_____________________________________________
b
was this property occupied by your spouse or did it remain unoccupied?
Yes
No
Part 2: Mark the statement to identify the proof of disability that qualifies you for the HEPD
If your proof of disability benefits has expired, terminated or switched to retirement from the prior assessment year, your CCAO may require
additional documentation. If you check “e” below, you must attach your completed Form PTAX-343-A. See instructions.
10 a
_______ Valid Class 2 or 2A Illinois Disabled Person Identification Card issued from the Illinois Secretary of State.
ID card number: _____________________________
Issue date: __ __/__ __/__ __ __ __
Class: _____________________________________
Expiration date: __ __/__ __/__ __ __ __
b
_______ Social Security Administration (SSA) disability benefits — Claim no.: _____________________
c
_______ Veterans Administration (VA) pension for a non-service connected disability — Claim/file no.: ___________________
d
_______ Railroad or Civil Service disability benefits for total (100%) disability — Claim/file no.: ___________________
e
Physician’s Statement for the
_______ Form PTAX-343-A,
Homestead Exemption for Persons with Disabilities.
Step 3:
Sign below
I state under penalties of perjury that to the best of my knowledge, the information contained in this application is true, correct, and complete.
____________________________________________________
___ ___/___ ___/___ ___ ___ ___
Property owner’s or authorized representative’s signature
Date
This form is authorized in accordance with the Illinois Property Tax Code. Disclosure of this information is required.
Failure to provide information may result in this form not being processed and may result in a penalty.
PTAX-343-R (R-08/15)
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