Fillable 2020-Senior-Freeze-Form-7-6-20 PTAX-340 2020 Senior Citizens Assessment Freeze Homestead Exemption Application and Affidavit

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2020-Senior-Freeze-Form-7-6-20 PTAX-340 2020 Senior Citizens Assessment Freeze Homestead Exemption Application and Affidavit

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PTAX-340 (R-05/20) 1 of 4
( ) -
PTAX-340
2020 Senior Citizens Assessment Freeze
Homestead Exemption Application and Affidavit
Last date to apply: ______________________________________
Part 1: Applicant information (Please type or print.)
1 ____________________________________________________________ 3 ____________________________________________
First name MI Last name Tax ID 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
County
2 ____________________________________________________________
Property (parcel) index number (PIN)
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 2019 - Include copy of pgs. 1, 2 & schedule 1 of 2019 Federal IRS Form 1040 for
you and all individuals living in home. Filer Exempt: Include copy of SSA-1099 and other 1099 for all living in home.
1 __________________|______
2 __________________|______
3 __________________|______
4 __________________|______
5 __________________|______
6 __________________|______
7 __________________|______
8 __________________|______
9 __________________|______
10 __________________|______
11 __________________|______
1
Total Gross Social Security and SSI benefits. Include Medicare deductions in this total.
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, Schedule 1, Line 22.
Subtraction item Amount
12a _______________________________________________ __________________|______
12b _______________________________________________ __________________|______
Add the amounts on Lines 12a and 12b, and write the result. 12 __________________|______
13 Subtract Line 12 from Line 11, and write the result. This is your total household income
for 2019. If the amount is greater than $65,000, STOP. You do not qualify for this exemption. 13 __________________|______
Do not write in this space.
Date received ___________________ Income verified
____
Yes
____
No
Application number ___________________ Base year EAV $__________________
Base year ___ ___ ___ ___ Revised base year EAV $__________________
Revised base year ___ ___ ___ ___ EAV of added improvements $__________________
Approved
____Ye s
____No
Base amount $__________________
Use your mouse or Tab key to move through the fields. Use your mouse or space bar to enable check boxes.
Part 4: Affidavit
Sworn under oath, I state the following:
1 (Mark the statement that applies.)
On January 1, 2020, 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
Rehabilitation Act of 2013.
_______________________________________ _________________________________________________
Name of facility Mailing address
2 (Mark the statement that applies.)
On January 1, 2020, 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, 2019.
4 (Mark the statement that applies.)
a ____ In 2020, I am, or will be, 65 years of age or older.
b ____ In 2020, my spouse, who died in 2020, would have been 65 years of age or older. (Complete the following information.)
_____________________________________________ __________________________________________________
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 2020.
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 2019 is $65,000 or less.
7 On January 1, 2020, 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, 2020. The total
income of all individuals and my spouse (regardless of his or her principal residence) are included in Part 3. (Attach an
additional sheet if necessary.)
First and last name Tax ID number
a __________________________________________________ __________________________________________________
b __________________________________________________ __________________________________________________
8 (Mark the statement that applies.)
On January 1, 2020, I was
a ____ single, widow(er), or divorced. b ____ married and living together. c ____ 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)
Note: The CCAO may conduct an audit to verify that the taxpayer is eligible to receive this exemption.
If you have any questions, please call:
Mail your completed Form PTAX-340 to:
(_________)_________ _________________________________
Last date to apply ___ ___/___ ___/___ ___ ___ ___
Month Day Year
_______________________________________________________
Mailing address
__________________________________IL _________________
City
ZIP
—
2 of 4 PTAX-340 (R-05/20)
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.
Printed by the authority of the
state of Illinois-Web only-1
Rebecca Tonigan
847
381
1120
28000 W Cuba Road
Barrington
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• cash assistance from the Illinois Department of Human
Services and other governmental cash public assistance
•
cash winnings from such sources as raffles and lotteries
• Civil Service benefits
• damages awarded in a lawsuit for nonphysical injury or
sickness (for example, age discrimination or injury to
reputation)
•
dividends
• farm income
• Illinois Income Tax refund (only if you received Form 1099-G)
• interest
• interest received on life insurance policies
• long term care insurance (federally taxable portion only)
• lump sum Social Security payments
• miscellaneous income, such as from rummage sales,
recycling aluminum, or baby sitting
•
military retirement pay based on age or length of service
• monthly insurance benefits
• pension and IRA benefits (federally taxable portion only)
•
Railroad Retirement benefits (including Medicare deductions)
• rental income
• Social Security income (including Medicare deductions)
• Supplemental Security Income (SSI) benefits
• all unemployment compensation
• wages, salaries, and tips from work
• Workers’ Compensation Act income
• Workers’ Occupational Diseases Act income
What is not included in household income?
Some examples of income that are not included in household
income are listed below. (For specific income questions, see
Part 3 on Page 4.)
•
cash gifts
• child support payments
• COBRA subsidy payments
• damages awarded in a lawsuit for a physical personal injury or
sickness
•
Energy Assistance payments
• federal income tax refunds
• IRA’s “rolled over” into other retirement accounts, unless
“rolled over” into a Roth IRA
•
lump sums from inheritances
• lump sums from insurance policies
• money borrowed against a life insurance policy or from any
financial institution
• reverse mortgage payments
•
spousal impoverishment payments
•
stipends from Foster Parent and Foster Grandparent programs
• Veterans’ benefits
What if I have a net operating loss or capital
loss carryover from a previous year?
You cannot include any carryover of net operating loss or capital
loss from a previous year. You can include only a net operating
loss or capital loss that occurred in 2019.
Will my information remain confidential?
All information received from your application is confidential and
may be used only for official purposes.
When must I file?
File Form PTAX-340 with the CCAO by the due date printed on
the bottom of Page 2. You must file Form PTAX-340 every year
and meet the qualifications for that year to continue to receive the
exemption.
Note: The CCAO may require additional documentation
(i.e., birth certificates, tax returns) to verify the information in this
application.
What if I need additional assistance?
If you have questions about this form, please contact your CCAO,
also known as the supervisor of assessments, or county assessor,
at the address and phone number printed at the bottom of Page 2.
What is the Senior Citizens Assessment Freeze
Homestead Exemption (SCAFHE)?
The Senior Citizens Assessment Freeze Homestead Exemption
(35 ILCS 200/15-172) allows you, as a qualified senior citizen, to
have your home’s equalized assessed value (EAV) “frozen” at a
base year value and prevent or limit any increase due to inflation.
The base year generally is the year before the year you first qualify
and apply for the exemption. For example, if you first qualify and
apply in 2020,
your property’s
EAV will be “frozen” at the 2019 EAV.
The amount of the exemption is the difference between your base
year EAV and your current year EAV. For Cook County only, the
amount of the exemption is the difference between your base
year EAV and your current year EAV or $2,000, whichever is
greater. Freezing your property’s EAV does not mean that your
property taxes will not increase, however. Other factors also affect
your tax bill. For example, your tax bill could increase if the tax
rate, which is based on the amount of revenues taxing districts
request, increases. Your EAV and tax bill may also increase if you
add improvements to your home. However, if your home’s EAV
decreases in the future, you will benefit from any reduction.
Who is eligible?
The senior citizens assessment freeze homestead exemption
qualifications for the 2020 tax year (for the property taxes you will
pay in 2021), are listed below.
• You will be 65 or older during 2020.
• Your total household income in 2019 was $65,000 or less.
• On January 1, 2019, and January 1, 2020, you
— used the property as your principal place of residence,
—
owned the property, or had a legal or equitable interest in
the property as evidenced by a written instrument, or had a
leasehold interest in the property used as a single-family
residence, and
— were liable for the payment of property taxes.
You do not qualify for this exemption if your property is assessed
under the mobile home privilege tax.
Surviving spouse — Even if you are not 65 or older during
2020, you are eligible for this exemption for 2020 (and possibly
2019) if your spouse died in 2020 and would have met all of the
qualifications.
Residents in a health facility — Even if you did not use the
property as your principal place of residence on January 1,
2020, you qualify for this exemption if you are 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 Rehabilitation Act of 2013 and you meet all other
requirements, have received this exemption previously, and your
property is either unoccupied or is occupied by your spouse.
Residents of cooperatives —
If you are a resident of a
cooperative apartment building or cooperative life-care facility,
you qualify for this exemption if you are liable for the payment of
the property taxes on your residence and meet the other eligibility
requirements.
What is a household?
A household includes you, your spouse, and all other persons
who used your residence as a principal dwelling place on
January 1, 2020.
What is included in household income?
Household income includes your income, your spouse’s income,
and the income of all individuals living in the household. Examples
of income that must be included in your household income are
listed below. (For specific questions, see Part 3 on Page 4.)
• alimony or maintenance received
• annuities and other pensions
• Black Lung benefits
• business income
• capital gains
PTAX-340 (R-05/20) 3 of 4
Form PTAX-340 General Information
Form PTAX-340 Step-by-Step Instructions
Part 1: Applicant information
Lines 1 through 5 — Type or print the requested information.
Part 2: Property information
Lines 1 and 2 — Identify the property for which this
application is filed.
Lines 3 and 4 — Answer the questions by marking an “X”
next to your statement. If you answered “Yes” to the question
on Line 3 and you know the base year, write it in the space
provided.
Part 3: Household income for 2019
“Income” for this exemption means 2019 federal adjusted gross
income, plus certain items subtracted from or not included in
your federal adjusted gross income (320 ILCS 25/3.07). These
include tax-exempt interest, dividends, annuities, net operating
loss carryovers, capital loss carryovers, and Social Security
benefits. Income also includes public assistance payments from
a governmental agency, SSI, and certain taxes paid. These
Step-by-Step Instructions provide federal return line references
and reporting statement references, whenever possible.
The amounts written on each line must include the 2019 income
for you, your spouse, and all the other individuals living in the
household.
Line 1 — Social Security and Supplemental Security
Income (SSI) benefits
Write the total amount of retirement, disability, or survivor’s
benefits (including Medicare deductions) the entire household
received from the Social Security Administration (shown on
Form SSA-1099, box 3 or use box 5 only if there is a reduction
of benefits). You also must include any Supplemental Security
Income (SSI) the entire household received and any benefits
to dependent children in the household. Do not include
reimbursements under Medicare/Medicaid for medical expenses.
Note: The amount deducted for Medicare ($1,608.00 yearly or
$134.00 per month, per person) is already included in the amount
in box 3 of Form SSA-1099.
Line 2 — Railroad Retirement benefits
Write the total amount of retirement, disability, or survivor’s
benefits (including Medicare deductions) the entire household
received under the Railroad Retirement Act (shown on Forms
SSA-1099 and RRB-1099).
Line 3 — Civil Service benefits
Write the total amount of retirement, disability, or survivor’s
benefits the entire household received under any Civil Service
retirement plan (shown on Form 1099-R).
Line 4 — Annuities and other retirement income
Write the total amount of income the entire household
received as an annuity from any annuity, endowment, life
insurance contract, or similar contract or agreement (shown
on Form 1099-R). Include only the federally taxable portion of
pensions, IRAs, and IRAs converted to Roth IRAs (shown on
U.S. 1040, Line 4b). IRAs are not taxable when “rolled over,”
unless “rolled over” into a Roth IRA.
Line 5 — Human Services and other governmental
cash public assistance benefits
Write the total amount of Human Services and other
governmental cash public assistance benefits the entire
household received. If the first two digits of any member’s Human
Services case number are the same as any of those in the
following list, you must include the total amount of any of these
benefits on Line 5.
01 aged 04 and 06 temporary assistance to
02 blind needy families (TANF)
03 disabled 07 general assistance
To determine the total amount of the household benefits, multiply
the monthly amount each person received by 12. You must
adjust your figures accordingly if anyone in the household did not
receive 12 equal checks during this period.
Food stamps and medical assistance benefits anyone in the
household may have received are not considered income and
should not be added to your total income.
Line 6 — Wages, salaries, and tips from work
Write the total amount of wages, salaries, and tips from work for
every household member (shown in box 1 of Form W-2).
Line 7 — Interest and dividends received
Write the total amount of interest and dividends the entire
household received from all sources, including any government
sources (shown on Forms 1099-INT, 1099-OID, and 1099-DIV).
You must include both taxable and nontaxable amounts.
Line 8 — Net rental, farm, and business income or (loss)
Write the total amount of net income or loss from rental, farm,
business sources, etc., the entire household received, as allowed
on U.S. 1040, Schedule 1, Lines 3, 5, and 6. You cannot use any
net operating loss (NOL) carryover in figuring income.
Line 9 — Net capital gain or (loss)
Write the total amount of taxable capital gain or loss the entire
household received in 2019, as allowed on U.S. 1040, Line 6 and
U.S. 1040, Schedule 1, Line 4. You cannot use a net capital loss
carryover in figuring income.
Line 10 — Other income or (loss)
Write the total amount of other income or loss not included in
Lines 1 through 9, that is included in federal adjusted gross
income, such as alimony received, unemployment compensation,
taxes withheld from oil or gas well royalties. You cannot use any
net operating loss (NOL) carryover in figuring income.
Line 11 — Add Lines 1 through 10.
Line 12 — Subtractions
You may subtract only the reported adjustments to income totaled
on U.S. 1040, Schedule 1, Line 22. For example
• IRA deduction • Educator expenses
• Archer MSA deduction • Tuition and fees
• moving expenses • Domestic production
• alimony or maintenance paid activities deduction
• health savings account deduction
• student loan interest deduction
• jury duty pay you gave to your employer
• deductible part of self-employment tax
• self-employed health insurance deduction
• self-employed SEP, SIMPLE, and qualified plans
• penalty on early withdrawal of savings
Line 13 — Total household income
Subtract Line 12 from Line 11. If this amount is greater than
$65,000, you do not qualify for this exemption. See Page 3.
Part 4: Affidavit
Lines 1 through 4 — Mark the item that applies. Read the
affidavit carefully. The statements must apply.
Line 7 — Write the names and tax identification numbers of the
individuals, other than yourself, who used the property for their
principal residence on January 1, 2020. Attach an additional
sheet if necessary.
Line 8 — Follow the instructions on the form. If your spouse
does not reside at this property, be sure to write his or her name
and address.
Note: You must sign your Form PTAX-340 before you file it with
your CCAO. Return your completed Form 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-05/20)
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2020-Senior-Freeze-Form-7-6-20 PTAX-340 2020 Senior Citizens Assessment Freeze Homestead Exemption Application and Affidavit

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Completed 12 July 2020

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