Ptax-300-H Form - Application For Hospital Property Tax Exemption - County Board Of Review Statement Of Facts

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Illinois Department of Revenue
PTAX-300-H
Application for Hospital Property Tax Exemption —
County Board of Review Statement of Facts
_______________
Complaint no.: _______________ Volume no.: _______________
IDOR docket number:
County use only
IDOR use only
Step 1: Identify the property
1
5
__________________________________________________
Date of ownership __ __/__ __/__ __ __ __
Name of hospital or affiliate applying for exemption
Attach a copy of proof of ownership (deed, contract for deed,
title insurance policy, condemnation order, and proof of
2
__________________________________________________
payment, etc.)
Street address of hospital or affiliate
6
Check the relevant hospital entity:
______________________________________IL __________
___ hospital owner - write the license number: ____________________
City
ZIP
___ hospital affiliate - explain relationship: _______________________
3
__________________________________________________
___ hospital system - explain relationship: _______________________
County in which hospital or affiliate is located
7
Property index numbers (PIN) included in your application for
4
Dimensions or acreage of this property___________________
exemption.
Attach a plot plan of each building’s location on the property
___________________________________________________
___________________________________________________
Attach a separate sheet if needed.
Attach a copy of the legal
description if the property is a division.
Step 2: Provide information about exemptions or applications
8
For what year is this exemption being sought? _________
9
E
If the applicant has an Illinois sales tax exemption number, write it here.
— ___ ___ ___ ___ — ___ ___ ___ ___
Step 3: Provide the following about the services and activities for the relevant hospital entity
10
Check what the value of services and activities below reflect: ____ hospital year ____average of 3 fiscal years ending with hospital year
11
What is your fiscal year? _________________
12
Write the amount of charity care provided.
12
Attach most recently filed Form AG-CBP-I.
_________________
13
Write the amount of unreimbursed costs for health services provided to low-income and underserved
individuals.
13
Attach a list of identifying activities or services provided.
_________________
14
If the hospital gives a subsidy to a state or local government, write the total amount.
Attach a list identifying
14
_________________
each entity and the amount.
15
15
If the hospital gives support for Illinois health care programs to low-income individuals, write the amount.
_________________
Attach the most recently filed federal Form 990, Schedule H.
16
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.
__________ / __________
X
$ _____________________
=
16
_________________
1) ratio
2) unreimbursed Medicare
17
If 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,
17
Worksheet C, Part 1.
_________________
18
18
Other. See instructions and identify: ______________________________________________________________
_________________
Step 4: Calculate and determine the exemption
19
19
Add Lines 12 through 18 and enter the total amount of services or activities provided.
_________________
20
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.
20
No. Write the estimated property tax amount from Schedule E, Line 18. Attach Schedule E.
_________________
If Line 20 is equal to or less than Line 19, you qualify for this exemption.
If Line 20 is greater than Line 19, you do not qualify for this exemption.
21
21
Is any part of this property leased?
Yes
No
If “yes”, attach a copy of any contracts or leases.
22
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?
22
Yes
No
Attach a copy of the notices and postal return receipts.
PTAX-300-H front (R-02/13)

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