Form Ptax-343-A - Physician'S Statement For The Homestead Exemption For Persons With Disabilities - 2013
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PTAX-343-A
Physician’s Statement for the Homestead
Exemption for Persons with Disabilities
Read this first
To qualify for the Homestead Exemption for Persons with Disabilities (HEPD), proof of a disability is required. The acceptable proof
of disability is listed on the back of this Form. If you are unable to provide any of these as proof of your disability, you and an Illinois
licensed physician must complete Form PTAX-343-A. You are responsible for any physicians’ costs.
Step 1:
Applicant - Complete the following information
1 ________________________________________________
3 Write the property index number (PIN) of the property for
Property owner’s name
which you are filing this form. Your PIN can be found on your
property tax bill or you may obtain it from your Chief County
________________________________________________
Assessment Officer (CCAO). If you are unable to obtain your
Street address of homestead property
PIN, write the legal description on Line b.
IL _____________
__________________________________
a
City
ZIP
PIN _________________________________________
(___ ___ ___)___ ___ ___ - ___ ___ ___ ___
b Attach a separate sheet if needed.
Daytime phone
_____________________________________________
PIN is your parcel number, you can find that
2 Write the assessment year for which you
___ ___ ___ ___
are requesting the HEPD:
on the top right corner of your property tax bill.
_____________________________________________
Year
Step 2:
Physician - Complete the following information
Part A: Patient information - Please print.
The patient must meet the disability criteria established by the Social Security Administration.
Note: Alcoholism or drug abuse is not included in the Social Security Administration’s guidelines as a qualification for disability status.
4 Patient’s name: ____________________________________
5 Date patient became disabled ___ ___/___ ___/___ ___ ___ ___
6 Can the patient do the same type of work as prior to their disability?
Yes
No
6a Was the patient able to work for a living after this date?
Yes
No
7 Has the disability lasted or is it expected to continue for 12 months or more?
Yes
No
8 Check all major body systems, disorders, and diseases of the patient’s disability:
Musculoskeletal
8.00
Skin
1.00
9.00
Special Senses and Speech
Endocrine
2.00
10.00
Respiratory
Impairments that Affect Multiple Body
3.00
Cardiovascular
11.00
Neurological
4.00
Digestive
12.00
Mental
5.00
Genitourinary
13.00
Malignant Neoplastic
6.00
Hematological
14.00
Immune
7.00
9 What is the nature of the disability? __________________________________________________________________________
Part B: Physician information
10 Name: __________________________________________
11 Your Illinois physician’s license number issued by the
0 3 6
Illinois Department of Financial and Professional Regulations:
- ___ ___ ___ ___ ___ ___
Sign below:
12
I have examined this patient and based on the Social Security Administration’s criteria for disability, I state that the
information contained in Step 2 is true, correct and complete to the best of my knowledge.
Physician’s signature: ___________________________________________________
Date: _____/_____/_____
PTAX-343-A (R-12/13)
IL-492-4547
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