Form Ptax-340 - Senior Citizens Assessment Freeze Homestead Exemption Application And Affidavit - 2014

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PTAX-340
2014 Senior Citizens Assessment Freeze
Homestead Exemption Application and Affidavit
Last date to apply:
______________________________________
Part 1: Applicant information
(Please type or print.)
1
3
____________________________________________________________
____________________________________________
First name
MI
Last name
Tax ID number
2
4
____________________________________________________________
____ ____ /____ ____ /____ ____ ____ ____
Mailing address
Date of birth (month, day, year)
(
)
-
5
____________________________________________________________
______________________ _____________________
City
State
ZIP
Area code and phone number
Email address
Part 2: Property information
1
_____________________________________________________________________________________________________________
Street address of property for which this exemption application is filed
Township
IL
__________________________________________
______________ ________________________________________________
City
ZIP
County
2
____________________________________________________________
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.
3
Have you or your spouse received this exemption for this property previously?
____
Yes
____
No
If you answered “Yes”, write the base year, if known.
____ ____ ____ ____
4
If your spouse maintains a separate residence, has he or she applied for this exemption?
Yes
No
____
____
Part 3: Household income for 2013
You must include the income of you, your spouse, and all other individuals who live in your household.
1
1
Social Security and SSI benefits. Include Medicare deductions in this total.
__________________|______
2
2
Railroad Retirement benefits. Include Medicare deductions in this total.
__________________|______
3
3
Civil Service benefits
__________________|______
4
4
Annuities, federally taxable pensions and retirement plan distributions.
__________________|______
5
5
Human Services and other governmental cash public assistance benefits
__________________|______
6
6
Wages, salaries, and tips from work
__________________|______
7
7
Interest and dividends received
__________________|______
8
8
Net rental, farm, and business income or (loss). (See instructions for Line 8.)
__________________|______
9
9
Net capital gain or (loss). (See instructions for Line 9.)
__________________|______
10
10
Other income or (loss). (See instructions for Line 10.)
__________________|______
11
11
Add Lines 1 through 10.
__________________|______
12
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
_______________________________________________
__________________|______
12
Add the amounts on Lines 12a and 12b, and write the result.
__________________|______
13
Subtract Line 12 from Line 11, and write the result. This is your total household income
13
STOP
for 2013. 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
Base amount
$__________________
____
____
Yes
No
PTAX-340 (R-12/13)
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