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Application For Hospital Property Tax Exemption (PTAX-300-H} - Illinois
| Application For Hospital Property Tax Exemption (PTAX-300-H} Form. This is a Illinois form and can be used in Miscellaneous Statewide . |
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IllinoisDepartmentofRevenue PTAX-300-H County use only ApplicationforHospitalPropertyTaxExemption-- CountyBoardofReviewStatementofFacts IDOR docket number: Complaint no.: _______________ Volume no.: _______________ _______________ IDOR use only Step1: Identifytheproperty 1 __________________________________________________ Name of hospital or affiliate applying for exemption Street address of hospital or affiliate City 4 Dimensions or acreage of this property___________________ Attach a plot plan of each building's location on the property 2 __________________________________________________ ______________________________________IL __________ ZIP 5 Date of ownership __ __/__ __/__ __ __ __ Attach a copy of proof of ownership (deed, contract for deed, title insurance policy, condemnation order, and proof of payment, etc.) 3 __________________________________________________ County in which hospital or affiliate is located 6 Check the relevant hospital entity: ___ hospital owner - write the license number: ____________________ ___ hospital affiliate - explain relationship: _______________________ ___ hospital system - explain relationship: _______________________ Step2:Provideinformationaboutexemptionsorapplications 7 Forwhat year is this exemption being sought? _________ 8 If the applicant has an Illinois sales tax exemption number, write it here. E-- ___ ___ ___ ___ -- ___ ___ ___ ___ Step3: Providethefollowingabouttheservicesandactivitiesfortherelevanthospitalentity 9 Check what the value of services and activities below reflect: ____ hospital year ____average of 3 fiscal years ending with hospital year 10 What is your fiscal year? _________________ 11 Write the amount of charity care provided. Attach most recently filed Form AG-CBP-I. 11 _________________ 12 Write the amount of unreimbursed costs for health services provided to low-income and underserved individuals. Attach a list of identifying activities or services provided. Attach a list identifying 12 _________________ 13 _________________ 14 _________________ 13If the hospital gives a subsidy to a state or local government, write the total amount. each entity and the amount. Attach the most recently filed federal Form 990, Schedule H. 14If the hospital gives support for Illinois health care programs to low-income individuals, write the amount. 15 If the hospital provides a dual-eligible subsidy by treating Medicare/Medicaid patients, multiply 1) the hospital's ratio of dual-eligible patients to the total number of Medicare patients by 2) the total of unreimbursed costs of Medicare. __________ / __________ 1) ratio X $ _____________________ 2) unreimbursed Medicare = 15 _________________ 16If the hospital provided relief for the government as it relates to health care services for low income individuals, write the total low-income portion of unreimbursed costs. Attach Schedule A and a copy of the CMS 2552-10, Worksheet C, Part 1. 16 _________________ 17Other. See instructions and identify: ______________________________________________________________ 17 _________________ Step4:Calculateanddeterminetheexemption 18 Add Lines 11 through 17 and enter the total amount of services or activities provided. 19 Has the property been assessed? Yes. Write the amount of the actual property tax from your property tax bill or the estimated property tax from Schedule E, Line 18, whichever is less. Attach the tax bill. No. Write the estimated property tax amount from Schedule E, Line 18. Attach Schedule E. If Line 19 is equal to or less than Line 18, you qualify for this exemption. If Line 19 is greater than Line 18, you do not qualify for this exemption. 18 _________________ 19 _________________ 20 Is any part of this property leased? 21 If "yes", attach a copy of any contracts or leases. 20 Yes No If the assessed or estimated assessed value is $100,000 or more, has the municipality, school district, community college district, and fire protection district in which the property is located been notified that this application has been filed? Attach a copy of the notices and postal return receipts. 21 Yes No American LegalNet, Inc. www.FormsWorkFlow.com PTAX-300-H front (R-08/12) Step5:dentifythepersontocontactregardingthisapplication I 22 ____________________________________________________ 23 _____________________________________________________ Name of applicant's representative Mailing address City Owner's name (if the applicant is not the owner) ____________________________________________________ ____________________________________________________ State ZIP _____________________________________________________ Mailing address City _____________________________________________________ State ZIP Phone number ( ) -- ____________________________________________________ ( ) -- _____________________________________________________ Phone number Step6: Signatureandnotarization 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 Countyofficialuseonly.Donotwritebelowthisline. Step7: Countyboardofreviewstatementoffacts Yes No If "Yes", write the Illinois Department of Revenue docket number for the exempt fee interest to the owner, if known. ___ ___ -- ___ ___ ___ -- ___ ___ ___ ___ 3 State all of the facts considered by the county board of review in recommending approval or denial of this exemption application. _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ 4 County board of review recommendation ___ Full year exemption ___ Partial year exemption from ___ ___ / ___ ___ / ___ ___ ___ ___ to ___ ___ / ___ ___ / ___ ___ ___ ___ ___ Partial exemption for the following described portion of the property: ___________________________________________________ _____
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