Illinois Department of Revenue Application for Hospital Property Tax Exemption — PTAX-300-H 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 4 Dimensions or acreage of this property___________________ Name of hospital or afiliate applying for exemption Attach a plot plan of each building’s location on the property 2 __________________________________________________ Date of ownership __ __/__ __/__ __ __ __ 5 Street address of hospital or afiliate Attach a copy of proof of ownership (deed, contract for deed, ______________________________________IL __________ title insurance policy, condemnation order, and proof of City ZIP payment, etc.) __________________________________________________ 3 6 Check the relevant hospital entity: County in which hospital or afiliate is located ___ hospital owner - write the license number: ____________________ ___ hospital afiliate - explain relationship: _______________________ ___ hospital system - explain relationship: _______________________ Step 2: Provide information about exemptions or applications 7 For what year is this exemption being sought? _________ 8 If the applicant has an Illinois sales tax exemption number, write it here. E — ___ ___ ___ ___ — ___ ___ ___ ___ Step 3: Provide the following about the services and activities for the relevant hospital entity 9 Check what the value of services and activities below relect: ____ hospital year ____average of 3 iscal years ending with hospital year 10 What is your iscal year? _________________ 11 Write the amount of charity care provided. Attach most recently iled 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. 12 _________________ 13 If the hospital gives a subsidy to a state or local government, write the total amount. Attach a list identifying each entity and the amount. 13 _________________ 14 If the hospital gives support for Illinois health care programs to low-income individuals, write the amount. 14 _________________ Attach the most recently iled federal Form 990, Schedule H. 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. __________ / __________ X $ _____________________ = 1) ratio 2) unreimbursed Medicare 15 _________________ 16 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, Worksheet C, Part 1. 16 _________________ 17 Other. See instructions and identify: ______________________________________________________________ 17 _________________ Step 4: Calculate and determine the exemption 18 Add Lines 11 through 17 and enter the total amount of services or activities provided. 18 _________________ 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. ttach the tax bill. A No . Write the estimated property tax amount from Schedule E, Line 18. Attach Schedule E. 19 _________________ 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. 20 Is any part of this property leased? 20 Yes No If “yes”, attach a copy of any contracts or leases. 21 If the assessed or estimated assessed value is $100,000 or more, has the municipality, school district, community college district, and ire protection district in which the property is located been notiied that this application has been iled? Attach a copy of the notices and postal return receipts. 21 Yes No PTAX-300-H front (R-08/12) = Page 1 = Step 5: Identify the person to contact regarding this application 22 ____________________________________________________ 23 _____________________________________________________ Name of applicant’s representative Owner’s name (if the applicant is not the owner) ____________________________________________________ _____________________________________________________ Mailing address Mailing address ____________________________________________________ _____________________________________________________ City State ZIP City State ZIP ( ) — ( _____________________________________________________ ) — ____________________________________________________ Phone number Phone number Step 6: Signature and notarization 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. _______________________________________________________ Afiant’s signature Subscribed and sworn to before me this _____ day of _____________________________, 2______. _______________________________________________________ Notary Public County oficial use only. Do not write below this line. Step 7: County board of review statement of facts 1 Current assessment $__________________________________ For assessment year 2_______ 2 Is this exemption application for a leasehold interest assessed to the applicant? 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: ___________________________________________________ ___ _______________________________________________________________________________________________________ ___ Deny exemption 5 Date of board’s action ___ ___ / ___ ___ / ___ ___ ___ ___ Step 8: County board of review certiication I certify this to be a correct statement of all facts arising in connection with proceedings on this exemption application. _______________________________________________________ Mail to: OFFICE OF LOCAL GOVERNMENT SERVICES MC 3-520 Signature of clerk of county board of review ILLINOIS DEPARTMENT OF REVENUE 101 WEST JEFFERSON STREET SPRINGFIELD IL 62702 This application must be completed in its entirety and all supporting documentation must be attached. All incomplete applications will be returned. PTAX-300-H back (R-08/12) = Page 2 = Step 1: Identify the property Line 13 — Subsidy of state or local governments — Direct or Line 4 — Write the dimensions (square footage) or acreage of this indirect inancial or in-kind subsidies of state or local governments property. Attach a plot plan of each building’s location and use by the Relevant Hospital Entity that pay for or subsidize activities of the property. or programs related to health care for low-income or underserved Line 5 — Write the date on which ownership began. Attach a copy individuals. of proof of ownership (deed, contract for deed, or title insurance Line 14 — Support for state health care programs for low- policy, etc. ). income individuals — At the election of the Hospital Applicant for Line 6 — Check the relevant hospital entity—hospital owner, hospital each applicable year, either afiliate, or hospital system. If you check “hospital afiliate” or “hos- • 10 percent of payments to the Relevant Hospital Entity and any pital system”, describe the type of entity ( e.g. , corporation, partner- Hospital Afiliate designated by the relevant Hospital Entity (pro- ship, limited liability company) and the relationship with one or more vided that such hospital afiliate’s operations provide inancial or hospital owners. operational support for or receive inancial or operational sup- port from the Relevant Hospital Entity) under Medicaid or other Deinitions means-tested programs, including, but not limited to, General Hospital - Any institution, place, building, buildings on a campus, or Assistance, the Covering ALL KIDS Health Insurance Act, and other health care facility located in Illinois that is licensed under the the State Children’s Health Insurance Program; or Hospital Licensing Act and has a hospital owner. • the amount of subsidy provided by the Relevant Hospital Entity and any hospital afiliate designated by the Relevant Hospital Hospital owner - A not-for-proit corporation that is the title holder Entity (provided that such hospital afiliate’s operations pro- of a hospital, or the owner of the beneicial interest in an Illinois land vide inancial or operational support for or receive inancial or trust that is the titleholder of a hospital. operational support from the Relevant Hospital Entity) to state or Hospital afiliate - Any corporation, partnership, limited partnership, local government in treating Medicaid recipients and recipients joint venture, limited liability company, association or other of means-tested programs, including but not limited to General organization, other than a hospital owner, that directly or indirectly Assistance, the Covering ALL KIDS Health Insurance Act, and controls, is controlled by, or is under common control with one or the State Children’s Health Insurance Program. more hospital owners and that supports, is supported by, or acts in The amount of subsidy for purposes of the item is calculated in the furtherance of the exempt health care purposes of at least one of same manner as unreimbursed costs are calculated for Medicaid those hospital owners’ hospitals. and other means-tested government programs on federal Form 990, Hospital system - A hospital and one or more other hospitals or Schedule H. Unreimbursed costs shall be net of fee-for-services pay- hospital afiliates related by common control or ownership. ments, payments pursuant to an assessment, quarterly payments, and all other payments included on the Schedule H. Step 2: Provide information about exemptions or Line 15 — Dual-eligible subsidy — This is the amount of subsidy applications provided to the government by treating dual-eligible Medicare/Med- icaid patients. The amount of subsidy is calculated by multiplying Follow the instructions on the form. the Relevant Hospital Entity’s ratio of dual-eligible patients to total Medicare patients by the Relevant Hospital Entity’s unreimbursed Step 3: Provide the following about the services costs for Medicare (calculated in the same manner as federal Form and activities for the relevant hospital entity 990, Schedule H). Line 9 — Check whether the igures for services and activities you Line 16 — Relief of the burden of government related to health will enter on Lines 11 through 17 are for the hospital year or the aver- care of low-income individuals — Complete Schedule A and at- age of the previous three iscal years ending with the hospital year. tach it and a copy of the CMS 2552-10 Worksheet C, Part 1 . Hospital year - The iscal year of the relevant hospital entity, or the Line 17 — Enter any other activity by the hospital that the depart- iscal year of one of the hospital owners in the hospital system if ment determines relieves the burden of government or addresses the the relevant hospital entity is a hospital system with members with health of low-income or underserved individuals. Clearly specify the different iscal years, that ends in the year for which the exemption is service or activity. Attach all supporting documentation. sought. Line 11 — Charity care — Free or discounted services provided pursuant to the Relevant Hospital Entity’s inancial assistance policy, Step 4: Calculate and determine the exemption measured at cost, including discounts provided under the Hospital Follow the instructions on the form. All lines must be completed. Uninsured Patient Act. Attach Form AG-CBP-I. Line 12 — Health services to low-income and underserved in- Step 5: Identify the person to contact regarding this dividuals — Unreimbursed costs of the Relevant Hospital Entity for application providing without charge, paying for, or subsidizing goods, activities, Follow the instructions on the form. or services for the purpose of addressing the health of low-income or underserved individuals. Those activities or services may in- Step 6: Signature and notarization clude, but are not limited to, inancial or in-kind support to afiliated or unafiliated hospitals, hospital afiliates, community clinics, or The application must be signed under oath, verifying that all of the programs that treat low-income or underserved individuals; providing information is true and correct to the best of the applicant’s knowl- or subsidizing outreach or educational services to low-income or un- edge and belief. This application must be notarized before sending derserved individuals for disease management and prevention; free to the county board of review. or subsidized goods, supplies, or services needed by low-income or underserved individuals because of their medical condition; and pre- natal or childbirth outreach to low-income or underserved persons. Attach a list of identifying activities or services provided. PTAX-300-H Instructions front (R-08/12) = Page 3 =