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Step 5: Identify the person to contact regarding this application

____________________________________________________

_____________________________________________________

Name of applicant’s representative

Owner’s name (if the applicant is not the owner)

____________________________________________________

_____________________________________________________

Mailing address

____________________________________________________

_____________________________________________________

City

State

ZIP

City

State

ZIP

(

)

—

(

)

—

____________________________________________________

_____________________________________________________

Phone number

Step 6: Signature and notarization

State of Illinois

) SS.

County of

________________________________________ )

I, ______________________________________, _____________________________, being duly sworn upon oath, say that I have read

Name

Position

the foregoing application and that all of the information is true and correct to the best of my knowledge and belief.

_______________________________________________________

Affiant’s signature

Subscribed and sworn to before me this _____ day of _____________________________, 2______.

_______________________________________________________

Notary Public

County official use only. Do not write below this line.

Step 7: County board of review statement of facts

Current assessment $__________________________________

For assessment year 2_______

Is this exemption application for a leasehold interest assessed to the applicant?

Yes

If “Yes”, write the Illinois Department of Revenue docket number for the exempt fee interest to the owner,

if known. ___ ___ — ___ ___ ___ — ___ ___ ___ ___

State all of the facts considered by the county board of review in recommending approval or denial of this exemption application.

_____________________________________________________________________________________________________________

County board of review recommendation

___ Full year exemption

___ Partial year exemption from ___ ___ / ___ ___ / ___ ___ ___ ___ to ___ ___ / ___ ___ / ___ ___ ___ ___

___ Partial exemption for the following described portion of the property: ___________________________________________________

__________________________________________________________________________________________________________

___ Deny exemption

Date of board’s action ___ ___ / ___ ___ / ___ ___ ___ ___

Step 8: County board of review certification

I certify this to be a correct statement of all facts arising in connection with proceedings on this exemption application.

Mail to: OFFICE OF LOCAL GOVERNMENT SERVICES MC 3-520

_______________________________________________________

Signature of clerk of county board of review

ILLINOIS DEPARTMENT OF REVENUE

101 WEST JEFFERSON STREET

SPRINGFIELD IL 62702

This application must be completed in its entirety and all supporting documentation must be attached. All

incomplete applications will be returned.

PTAX-300-H back (R-02/13)

Ptax-300-H Form - Application For Hospital Property Tax Exemption - County Board Of Review Statement Of Facts Page 2

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