Form Ptax-340 - Senior Citizens Assessment Freeze Homestead Exemption Application And Affidavit - 2015 Page 4
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4Form PTAX-340 Step-by-Step Instructions
Part 1: Applicant information
To determine the total amount of the household benefits, multi-
ply the monthly amount each person received by 12. You must
Lines 1 through 5 — Type or print the requested information.
adjust your figures accordingly if anyone in the household did not
Part 2: Property information
receive 12 equal checks during this period.
Lines 1 and 2 — Identify the property for which this applica-
Food stamps, and medical assistance benefits anyone in the
tion is filed.
household may have received are not considered income and
should not be added to your total income.
Lines 3 and 4 — Answer the questions by marking an “X”
next to your statement. If you answered “Yes” to the question
Line 6 — Wages, salaries, and tips from work
on Line 3 and you know the base year, write it in the space
Write the total amount of wages, salaries, and tips from work for
provided.
every household member (shown in box 1 of Form W-2).
Part 3: Household income for 2014
Line 7 — Interest and dividends received
Write the total amount of interest and dividends the entire house-
“Income” for this exemption means 2014 federal adjusted gross
hold received from all sources, including any government sources
income, plus certain items subtracted from or not included in
(shown on Forms 1099-INT, 1099-OID, and 1099-DIV). You must
your federal adjusted gross income (320 ILCS 25/3.07). These in-
include both taxable and nontaxable amounts.
clude tax-exempt interest, dividends, annuities, net operating loss
carryovers, capital loss carryovers, and Social Security benefits.
Line 8 — Net rental, farm, and business income or (loss)
Income also includes public assistance payments from a govern-
Write the total amount of net income or loss from rental, farm,
mental agency, SSI, and certain taxes paid. These Step-by-Step
business sources, etc., the entire household received, as allowed
Instructions provide federal return line references and reporting
on U.S. 1040, Lines 12, 17, and 18. You cannot use any net oper-
statement references, whenever possible.
ating loss (NOL) carryover in figuring income.
The amounts written on each line must include the 2014 income
Line 9 — Net capital gain or (loss)
for you, your spouse, and all the other individuals living in the
Write the total amount of taxable capital gain or loss the entire
household.
household received in 2014, as allowed on U.S. 1040, Lines 13
Line 1 — Social Security and Supplemental Security
and 14, or U.S. 1040A, Line 10. You cannot use a net capital loss
Income (SSI) benefits
carryover in figuring income.
Write the total amount of retirement, disability, or survivor’s
Line 10 — Other income or (loss)
benefits (including Medicare deductions) the entire household
Write the total amount of other income or loss not included in
received from the Social Security Administration (shown on Form
Lines 1 through 9, that is included in federal adjusted gross
SSA-1099, box 3 or use box 5 only if there is a reduction of ben-
income, such as alimony received, unemployment compensation,
efits). You also must include any Supplemental Security Income
taxes withheld from oil or gas well royalties. You cannot use any
(SSI) the entire household received and any benefits to depen-
net operating loss (NOL) carryover in figuring income.
dent children in the household. Do not include reimbursements
Line 11
under Medicare/Medicaid for medical expenses.
— Add Lines 1 through 10.
Note: The amount deducted for Medicare ($1,258.80 yearly or
Line 12 — Subtractions
$104.90 per month, per person) is already included in the amount
You may subtract only the reported adjustments to income totaled
in box 3 of Form SSA-1099.
on U.S. 1040, Line 36 or U.S. 1040A, Line 20. For example
Line 2 — Railroad Retirement benefits
• IRA deduction
• Educator expenses
• Archer MSA deduction
• Tuition and fees
Write the total amount of retirement, disability, or survivor’s bene-
• moving expenses
• Domestic production
fits (including Medicare deductions) the entire household received
• alimony or maintenance paid
activities deduction
under the Railroad Retirement Act (shown on Forms SSA-1099
• health savings account deduction
and RRB-1099).
• student loan interest deduction
Line 3 — Civil Service benefits
• jury duty pay you gave to your employer
Write the total amount of retirement, disability, or survivor’s
• deductible part of self-employment tax
benefits the entire household received under any Civil Service
• self-employed health insurance deduction
retirement plan (shown on Form 1099-R).
• self-employed SEP, SIMPLE, and qualified plans
Line 4 — Annuities and other retirement income
• penalty on early withdrawal of savings
Write the total amount of income the entire household received
Line 13 — Total household income
as an annuity from any annuity, endowment, life insurance con-
Subtract Line 12 from Line 11. If this amount is greater than
tract, or similar contract or agreement (shown on Form 1099-R).
$55,000, you do not qualify for this exemption. See Page 3.
Include only the federally taxable portion of pensions, IRAs, and
Part 4: Affidavit
IRAs converted to Roth IRAs (shown on U.S. 1040, Line 15b and
Lines 1 through 4
— Mark the item that applies. Read the af-
16b, or U.S. 1040A, Line 11b and 12b). IRA’s are not taxable
fidavit carefully. The statements must apply.
when “rolled over,” unless “rolled over” into a Roth IRA.
Line 7
— Write the names and tax identification numbers of the
Line 5 — Human Services and other governmental
individuals, other than yourself, who used the property for their
cash public assistance benefits
principal residence on January 1, 2015. Attach an additional
Write the total amount of Human Services and other governmen-
sheet if necessary.
tal cash public assistance benefits the entire household received.
Line 8
— Follow the instructions on the form. If your spouse
If the first two digits of any member’s Human Services case num-
does not reside at this property, be sure to write his or her name
ber are the same as any of those in the following list, you must
and address.
include the total amount of any of these benefits on Line 5.
01 aged
04 and 06 temporary assistance to
Note: You must sign your Form PTAX-340 and have it notarized
02 blind
needy families (TANF)
before you file it with your CCAO. Return your completed Form
03 disabled
07 general assistance
PTAX-340 to your CCAO’s office or mail it to the address printed
on the bottom of Page 2.
4 of 4
PTAX-340 (R-12/14)
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