Fill - Free fillable EXEMPTION APPLICATION FOR TAX YEAR 2021 PDF form

1. Social Security, SSI benefits.

Include Medicare deductions.

2. Railroad Retirement benefits.

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).

9. Net capital gain (or loss).

10. Other income (or loss).

11. Subtotal: Add Lines 1 through 10

12. Certain subtractions. You may subtract only

the reported adjustments to income from

2020 U.S. 1040, Schedule 1, Line 22

13. Total Household Income:

Subtract Line 12 from Line 11

If Line 13 is less than or equal to $65,000 this household

does meet income qualifications for the “Senior Freeze."

Include the household total for all income entered.

To be eligible for this exemption, the household (applicant, applicant’s

spouse, and all persons using the property as their principal residence)

must have had a combined income of $65,000 or less for calendar

year 2020. Please complete this worksheet to determine your eligibility.

The names of all persons who used this property as their principal

residence as of January 1, 2021:

YOU:

OTHERS:

COOK COUNTY ASSESSOR

FRITZ KAEGI

EXEMPTION APPLICATION FOR TAX YEAR 2021

Property Address City

Name of Applicant Phone Number Email address

Mailing Address (If different from property address) City State Zip Code Date of Occupancy

Optional: Last 4 digits of applicant’s Social Security Number:

Choose Eligible Exemption(s) / Verify Required Documents

I occupied the property as my principal residence on or before

January 1, 2021.

I am liable for the payment of this property’s taxes.

I own this property or have a legal, equitable,

or leasehold interest in this property.

Homeowner Exemption

Check-mark all exemptions for which you qualify and would like to apply. You may choose multiple exemptions.

I hereby apply for the Homeowner Exemption

STEP 2

I occupied the property as my principal place of residence in 2021.

I am liable for the payment of this property’s taxes.

I own this property or have a legal, equitable,

or leasehold interest in this property.

I was born in or before 1956. Enter date of birth: _____________

Senior Exemption

I hereby apply for the Senior Exemption

Senior Freeze Exemption

I hereby apply for the Senior Freeze Exemption

✓

Property Information

STEP 1

Your application is NOT COMPLETE. TURN PAGE OVER to complete your application.

Apply Online:

Scan the QR code or visit

cookcountyassessor.com

Required Income Verification

Property Index Number(PIN)

Check the box to receive news from the Assessor’s Office

The Total Household Income at this property was $65,000

or less in income tax year 2020.

This property was my principal place of residence on

January 1, 2020 and January 1, 2021.

I own this property or have a legal, equitable, or leasehold

interest in this property January 1, 2020 and January 1, 2021.

I was/am liable for the payment of this property’s 2020

and 2021 property taxes.

Note: this exemption is subject to an audit by the Cook County

Assessor’s Office. Signing a fraudulent application for this

exemption is perjury as defined in Section 32-2 of the

Illinilois Criminal Code of 2012.

THE INCOME VERIFICATION TO

THE RIGHT MUST BE COMPLETED.

MM/DD/YYYY

All applications must include Photo ID. The name and address on the ID must match what

is entered on the application, and been issued before January 1 of the Tax Year. If your

current name is different from a former name on any provided verification document(s) or

the deed, you must submit documentation sufficient to explain the name change: a certified

marriage certificate, divorce decree, etc. If you do not own the property, you must submit

documentation showing a legal, equitable, or leasehold interest in the property.

Attach copies of one from List A or one from List B AND one from List C

Photo IDs that verify

identity and occupancy

in the tax year.

• Drivers License / IL ID Card

• Matrícula Consular ID

• City of Chicago ID Card

• IL Drivers License / IL ID Card

• Matrícula Consular ID

• City of Chicago ID Card

• US Passport

• US Military ID Card

• Certificate of Naturalization (N-550/N-570)

• Permanent Resident Card (I-551)

• Refugee Travel Document (I-571)

• Employment Authorization (I-766)

Items in List C must include the property

address and reflect the 2021 tax year.

• Mailed bank statement

• Mailed landline, cable, or internet bill

• Mailed pay stub

• Social Security Award Letter

• Voting record

(from Cook County Clerk’s Office

or Chicago Board of Elections)

If the address on your Photo ID doesn't reflect the property address,

provide one photo ID from List B and one document from List C.

Class 2 or 2A Illinois Disabled Person ID Card from the

Illinois Secretary of State's Office.

Proof of SSA Disability Benefits which includes: an award

letter, verification letter, annual COLA letter. If you are under

the age of 65 and receiving SSI disability benefits, include a

letter indicating SSI payments.

Proof of Department of Veterans Affairs disability benefits

which includes an award letter or certification letter indicating

you are receiving pension for a non service connected

disability.

Proof of pension for non-military service connected disability.

Proof of Railroad or Civil Service Disability benefits which

includes an award letter or verification letter of total (100%)

disability.

If you are unable to provide proof of your disability listed on

the items above, you must submit Form PTAX 343-A,

Physician's Statement for Proof of Disability, completed by a

physician. [Note: You may also be required to be

re-examined by an IDOR designated physician. You would

be responsible for any cost incurred for your examination by

any physician.]

Disability certification or verification letter from the U.S.

Department of Veterans Affairs (VA) stating the applicant

[veteran] has a service-connected disability for the tax year

being applied for. The document must specify the percentage

of the service-connected disability and specify the effective date.

Form DD214 or separation of service from the War

Department (military service prior to 1950), or Certification of

Military Service Form.

A non-remarried surviving spouse of a disabled veteran

applying for the first time or transferring the exemption must

also provide their marriage certificate, the disabled veteran's

death certificate, and proof of property ownership.

I was or became disabled during the tax year I am

applying for exemption.

I occupied the property as my principal residence on or

before January 1, 2021; or

I was a resident of a life care facility licensed under the

Nursing Home Care Act and my property remained

unoccupied or was occupied by my spouse.

I am liable for the payment of this property’s taxes.

I own this property or have a legal, equitable, or leasehold

interest in this property.

✓

Persons with Disabilities Exemption

I hereby apply for the Persons with Disabilities Exemption

To the best of my knowledge, the information

contained in this application is true, correct and

complete. I understand that if an exemption is

granted in error, this property may be subject to a lien

for back taxes and penalties in accordance with

Section 9-275 of the Illinois Property Tax Code.

I affirm that neither I nor my spouse (if any) have applied

for a Homestead Exemption on any other property.

If you are completing a paper form, mail a completed

form with applicable documentation to:

Cook County Assessor

118 N. Clark Street, Room 320

Chicago, IL 60602

Applicant’s Name

Applicant’s Signature

Date

Veterans with Disabilities Exemption

I hereby apply for the Veterans with Disabilities Exemption

Signature

STEP 4

Verify Identity and Occupancy of this Property

B C

STEP 3

Required Documents

One of the following documents must be provided with this

application. Check-mark the documentation you are including.

Required Documents

Applicants must submit a certification letter from the VA and

a DD214. Check-mark the documents you are including in

this application.

If you are returning from active duty in an armed conflict

involving the armed forces of the U.S., visit

cookcountyassessor.com/returning-veterans-exemption

to apply separately for the Returning Veterans Exemptions.

Questions? Please call us at (312) 443-7550 for help in English, Español, and Polskim.

I occupied the property as my principal place of residence in 2021.

I have at least 30% service connected disability certified by

the US Department of Veteran Affairs during tax year 2021.

I am liable for the payment of this property’s taxes.

I own this property or have a legal, equitable, or leasehold

interest in this property.

I am an Illinois resident who has served as a member of the US

Armed Forces on active duty or State active duty, in IL National

Guard or US Reserve Forces and I was honorably discharged.

I am a non-remarried Surviving spouse of a disabled veteran;

if YES, complete the following:

Deceased Disabled Veteran's Name:

_________________________________________________

Date of Death: ______________

MM/DD/YYYY

12/22/2010

1 of 1

CCUPANCY AFFIDAVIT

Affiant’s Name: _________________________

Affiant's Current Address: _____________________________________________________

Phone #:

(_____)___________________

I, _________________________________________, do hereby state under oath as follows:

the property commonly known as _______________________________________________ and

From _______________ to _________________, I occupied as my principal residence

(Affiant’s name)

(property address, city, state and zip code)

(date) (date)

(property address, city, state and zip code)

COOK COUNTY ASSESSOR

RITZ KAEGI

COOK COUNTY ASSESSOR’S OFFICE

118

NORTH CLARK STREET, 3

FLOOR

CHICAGO, IL 60602 | PHONE: 312.443.7550

WWW.COOKCOUNTYASSESSOR.COM

identified by Property Index Number(s) ___________________________________________,

and I did not request or receive a homestead exemption on a different property for any of those years.

I swear that the facts stated above are true and complete.

___________________________________________

Signature of Affiant (required)

Updated March 23, 2020

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

EXEMPTION APPLICATION FOR TAX YEAR 2021

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank EXEMPTION APPLICATION FOR TAX YEAR 2021 Form

Related forms

Fillable EXEMPTION APPLICATION FOR TAX YEAR 2021

Fill Online, Printable, Fillable, Blank EXEMPTION APPLICATION FOR TAX YEAR 2021 Form

Related forms

First 20 documents completely FREE!