Form Ptax-340 - Senior Citizens Assessment Freeze Homestead Exemption Application And Affidavit - 2017 Page 2

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Part 4: Affidavit
Sworn under oath, I state the following:
1
(Mark the statement that applies.)
On January 1, 2017, the property identified in Part 2, Line 1, was improved with a permanent structure
a
that I used as my principal residence.
____
b
for which I received this exemption previously and is either unoccupied or used as my spouse’s principal residence. I
____
am now a resident of a facility licensed under the Assisted Living and Shared Housing Act, Nursing Home Care Act,
ID/DD (intellectually disabled/developmentally disabled) Community Care Act, or Specialized Mental Health Rehabili-
tation Act of 2013.
_______________________________________
_________________________________________________
Name of facility
Mailing address
2
(Mark the statement that applies.)
On January 1, 2017,
I
a
was the owner of record of the property identified in Part 2, Line 1.
____
b
had a legal or equitable interest by a written instrument in the property listed in Part 2, Line 1.
____
c
____
had a leasehold interest in the property identified in Part 2, Line 1, that was used as a single-family residence.
3
I am liable for paying real property taxes on the property identified in Part 2, Line 1.
Note:
If I have not received this exemption for this property previously, I also met the eligibility requirements listed in Part 4,
Lines 1, 2, and 3 for this property on January 1, 2016.
4
(Mark the statement that applies.)
a
____ In 2017,
I am, or will be, 65 years of age or older.
b
my s pouse, who died in 2017, would have been 65 years of age or older. (Complete the following information.)
____ In 2017,
_____________________________________________
__________________________________________________
Deceased spouse’s name
Tax ID number
____ ____ /____ ____ /____ ____ ____ ____
____ ____ /____ ____ /____ ____ ____ ____
Date of birth (month, day, year)
Date of death (month, day, year)
5
The property identified in Part 2, Line 1, is the only property for which I am applying for a senior citizens assessment freeze
homestead exemption for 201 7 .
6
The amount reported in Part 3, Line 13, of this form includes the income of my spouse and all persons living in my household
and the total household income for 201 6 is $55,000 or less.
7
On January 1, 201 7 , the following individuals also used the property identified in Part 2, Line 1, for their principal residence.
My spouse is included if he or she used the property as his or her principal dwelling place on January 1, 201 7 . The total
income of all individuals and my spouse (regardless of his or her principal residence) are included in Part 3. (Attach an ad-
ditional sheet if necessary.)
First and last name
Tax ID number
a
__________________________________________________
__________________________________________________
b
__________________________________________________
__________________________________________________
8
(Mark the statement that applies.)
On January 1, 201 7 , I was
a
b
c
single, widow(er), or divorced.
____ married and living together.
married, but not living together.
____
____
My spouse’s name and address is
_____________________________________________________________________________
First name
MI
Last name
_____________________________________________________________________________________________________________
Street Address
City
State
ZIP
Under penalties of perjury, I state that, to the best of my knowledge, the information contained in this affidavit is true, correct, and complete.
_______________________________________ ____ ____/____ ____/____ ____ ____ ____
Signature of applicant
Date (month, day, year)
Subscribed and sworn to before me this
day of
20
_______
________________________________,
_____.
____________________________________________________
Notary public
Note: The CCAO may conduct an audit to verify that the taxpayer is eligible to receive this exemption.
Mail your completed Form PTAX-340 to:
If you have any questions, please call:
_________________Co. Chief County Assessment Officer
(_________)_________ _________________________________
—
_______________________________________________________
Last date to apply ___ ___/___ ___/___ ___ ___ ___
Mailing address
Month
Day
Year
____________________________________IL _________________
ZIP
City
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.
2 of 4
PTAX-340 (R-12/16)
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