Senior Freeze Exemption - Cook County Assessor

Senior Freeze Exemption - Cook County Assessor - 2016 Page 2

OOK

OUNTY

SSESSOR

OSEPH

ERRIOS

201 SENIOR FREEZE EXEMPTION

7. My total household income, including my income and the income of all persons listed on number 6 on the

previous page, for income ax ear 201 , was (use the instructions on the next page):

Social Security

SSI benefits nclude Medicare deductions .………………………..…..

Railroad Retirement benefits nclude Medicare deductions ….………………………....

Civil Service benefits……………………………………………………..………………...

Annuity benefits and federally taxable pension and IRA benefits……...………………...

Human Services and other governmental assistance……………………………….….....

Wages, salaries and tips from work….…………………………………………………..

Interest and dividends received…………………….………………………..………….…....

Net rental, farm and business income (or loss) …………………………..….……...…….

Net capital gain (or loss)……….………….…………………………………..………………..

Other income (or loss)……………………………………………………….………………....

Add Lines A through J………………………………………….………………..………….

Subtractions…………………...…………………….………………….……

Subtract Line L from Line K and

the result………………..…………………

....

If Line M is MORE THAN $55,000 ,

you do not qualify for the Senior Freeze Exemption

Under penalt

of perjury, I state that, to

Applicant's Name

the best of my knowledge, the information

contained in this affidavit is true, correct

and complete.

Applicant's Signature

Please note: This exemption is subject to

Date

audit by the Cook County Assessor’s Office.

Senior Freeze Exemption - Cook County Assessor - 2016 Page 2