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

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PTAX-340
2014 Senior Citizens Assessment Freeze
Homestead Exemption Application and Affidavit
Last date to apply: December 31, 2014
Part 1: Applicant information
(Please type or print.)
1
3=-=-~----------------------
First name
Ml
Last name
Tax 10 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
2
--------~--~~~-----------------------­
Property (parcel) index number (PIN)
County
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 Social Security and SSI benefits. Include Medicare deductions in this total.
1
___________ I _ _
2
Railroad Retirement benefits. Include Medicare deductions in this total.
3 Civil Service benefits
4
Annuities, federally taxable pensions and retirement plan distributions.
5
Human Services and other governmental cash public assistance benefits
6
Wages, salaries, and tips from work
7
Interest and dividends received
8
Net rental, farm, and business income or (loss).
(See
instructions for Line 8.)
9
Net capital gain or (loss).
(See
instructions for Line 9.)
10 Other income or (loss).
(See
instructions for Line 10.)
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. 1 040A, Line 20.
Subtraction item
Amount
12a________________________________ _ ___________ I __ __
12b________________________________ _ ___________ , I
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
2
I _ _
3
I
4 __________ _
5
6
7
________ I ___
8 ______ __
9 ______ __
10 _ _ _ _ _ _ _
11 ______ _
12 _ _ _ _ _ _
for 2013. If the amount is greater than $55,000,
STOP.
You do not qualify for this exemption.13 ________
l _ _
Date received
Application number
Base year
Revised base year
Approved
___ Yes
No
Do not write in this space.
Income verified
Base year EAV
Revised base year EAV
EAV of added improvements
Base amount
Yes
No
-$-
$ ___________ _
$ ___________ _
$ _ _ _ _ _ _ _ __

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