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PTAX-340

2013 Senior Citizens Assessment Freeze

Homestead Exemption Application and Afﬁdavit

07/01/2013

Last date to apply:

______________________________________

Part 1: Applicant information

(Please type or print.)

____________________________________________________________

____________________________________________

First name

Last name

Tax ID number

____________________________________________________________

____ ____ /____ ____ /____ ____ ____ ____

Mailing address

Date of birth (month, day, year)

(

)

____________________________________________________________

______________________ _____________________

City

State

ZIP

Area code and phone number

Email address

Part 2: Property information

_____________________________________________________________________________________________________________

Street address of property for which this exemption application is ﬁled

Township

__________________________________________

______________ ________________________________________________

City

ZIP

County

____________________________________________________________

Property (parcel) index number (PIN)

Note: The PIN is shown on your property tax bill. You also may obtain it from your chief county assessment ofﬁcer

(CCAO). If you cannot obtain the PIN, attach a copy of the legal description.

Have you or your spouse received this exemption for this property previously?

Yes

____

If you answered “Yes”, write the base year, if known.

____ ____ ____ ____

If your spouse maintains a separate residence, has he or she applied for this exemption?

Yes

____

Part 3: Household income for 2012

You must include the income of you, your spouse, and all other individuals who live in your household.

Social Security and SSI beneﬁts. Include Medicare deductions in this total.

__________________|______

Railroad Retirement beneﬁts. Include Medicare deductions in this total.

__________________|______

Civil Service beneﬁts

__________________|______

Annuities, federally taxable pensions and retirement plan distributions.

__________________|______

Human Services and other governmental cash public assistance beneﬁts

__________________|______

Wages, salaries, and tips from work

__________________|______

Interest and dividends received

__________________|______

Net rental, farm, and business income or (loss). (See instructions for Line 8.)

__________________|______

Net capital gain or (loss). (See instructions for Line 9.)

__________________|______

Other income or (loss). (See instructions for Line 10.)

__________________|______

Add Lines 1 through 10.

__________________|______

Certain subtractions. You may subtract only the reported adjustments to income from

U.S. 1040, Line 36, or U.S. 1040A, Line 20.

Subtraction item

Amount

12a

_______________________________________________

__________________|______

12b

_______________________________________________

__________________|______

Add the amounts on Lines 12a and 12b, and write the result.

__________________|______

Subtract Line 12 from Line 11, and write the result. This is your total household income

STOP

for 2012. If the amount is greater than $55,000,

. You do not qualify for this exemption.

__________________|______

Do not write in this space.

Date received

___________________

Income veriﬁed

___ Yes

___ No

Application number

___________________

Base year EAV

$__________________

Base year

___ ___ ___ ___

Revised base year EAV

$__________________

Revised base year

___ ___ ___ ___

EAV of added improvements

$__________________

Approved

___ Yes

___ No

Base amount

$__________________

PTAX-340 (R-1/13)

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Form Ptax-340 - Senior Citizens Assessment Freeze - Homestead Exemption Application And Affidavit - 2013

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