PTAX-343-A: Illinois Physician’s Statement for the Homestead Exemption for Persons with Disabilities

Step 1: Applicant - Complete the following information: Property owner's name, Street address of homestead property, City, ZIP and Daytime phone.

Write the assessment year for which you are requesting the HEPD.

3 Write the property index number (PIN) of the property for 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 PIN, write the legal description on Line b. Attach a separate sheet if needed.

Step 2: Physician, Advanced Practice Nurse, Physician Assistant, or Optometrist - 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.

Enter the Patient's name and the Date patient became disabled.

Mark Yes or No: Can the patient do the same type of work as prior to their disability? Was the patient able to work for a living after this date?

Mark Yes or No: Has the disability lasted or is it expected to continue for 12 months or more?

Check all major body systems, disorders, and diseases of the patient's disability: Musculoskeletal, Special Senses and Speech, Respiratory, Cardiovascular, Digestive, Genitourinary, Hematological, Skin, Endocrine, Congenital disorders that Affect Multiple Body Systems, Neurological, Mental, Cancer (Malignant Neoplastic Diseases) and Immune.

Enter the nature of the disability.

Part B: Physician, Advanced Practice Nurse, Physician Assistant, or Optometrist information: Name, then enter your license number and issuing state: License number and State.

12 In Part B, sign: 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.

Note: Certification by a licensed Optometrist is limited to disabilities related to visual impairment.

You must file Form PTAX-343-A with your Chief County Assessment Officer (CCAO) prior to your county's due date for the Homestead Exemption for Persons with Disabilities (HEPD).

You are responsible for any physicians' costs.

The acceptable proof of disability is listed on page 2 of the form. If you are unable to provide any of these as proof of your disability, you and a licensed physician, advanced practice nurse, physician assistant, or optometrist must complete Form PTAX-343-A. 1 A Class 2 Illinois Person with a Disability Identification Card from the Illinois Secretary of State's Office. Class 2 or Class 2A qualifies, Class 1 or 1A does not qualify. 2 Proof of Social Security Administration (SSA) disability benefits which includes an award letter, verification letter or annual Cost of Living Adjustment (COLA) letter (only Form SSA-4926-SM-DI). If you are under the age of 65 receiving Supplemental Security Income (SSI) disability benefits, proof includes a letter indicating SSI payments (SSA-L8151, SSA-L8155, or SSA-L8156). 3 Proof of Veterans Administration disability benefits which includes an award letter or verification letter indicating you are receiving a pension for a non-service connected disability. 4 Proof of Railroad or Civil Service disability benefits which includes an award letter or verification letter of total (100%) disability.