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PTAX-343-A Physician’s Statement for Disabled Persons’ Homestead Exemption PTAX-343-A (R-11/11) IL-492-4547 Read this first To qualify for the Disabled Persons’ Homestead Exemption (DPHE), proof of a disability is required. The acceptable proof of disabil ity 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. 1 Property owner’s name Street address of homestead property City ZIP - Daytime phone 2 Write the assessment year for which you are requesting the DPHE: Year 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. a PIN b Attach a separate sheet if needed. 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: 1.00 Musculoskeletal 8.00 Skin 2.00 Special Senses and Speech 9.00 Endocrine 3.00 Respiratory 10.00 Impairments that Affect Multiple Body 4.00 Cardiovascular 11.00 Neurological 5.00 Digestive 12.00 Mental 6.00 Genitourinary 13.00 Malignant Neoplastic 7.00 Hematological 14.00 Immune 9 What is the nature of the disability? Part B: Physician information 10 Name: 11 Your Illinois physician’s license number issued by the Illinois Department of Financial and Professional Regulations: 0 3 6 - 12 Sign below: 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: Step 1: Applicant - Complete the following information Use your mouse or Tab key to move through the fields. Use your mouse or space bar to enable check boxes. ---PAGE BREAK--- When and where must I file this Form PTAX-343-A? You must file Form PTAX-343- A with your Chief County Assessment Officer (CCAO) at the address shown below prior to your county’s due date for the Disabled Persons’ Homestead Exemption (DPHE). Contact your CCAO at the telephone number or address below for assistance. File or mail your completed Form PTAX-343-A: County, CCAO Mailing address City IL ZIP If you have any questions, please call: General Information To qualify for the Disabled Persons’ Homestead Exemption (DPHE), proof of a disability is required. The acceptable proof of disability is listed below. 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. What is considered proof of disability? 1 A Class 2 Illinois Disabled Person 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. Official use. Do not write in this space. Date received: Month Day Year PTAX-343-A (R-11/11) Social Security Administration’s Listing of Impairments 1.00 Musculoskeletal System 2.00 Special Senses and Speech 3.00 Respiratory System 4.00 Cardiovascular System 5.00 Digestive System 6.00 Genitourinary System 7.00 Hematological Disorders The Listing of Impairments describes, for each major body system, impairments that are considered severe enough to prevent a person from doing any gainful activity. Most of the listed impairments are permanent or expected to result in death, or a specific state ment of duration is made. For all others, the evidence must show that the impairment has lasted or is expected to last for a continuous period of at least 12 months. The criteria in the listing of impairments are applicable to evaluation of claims for disability benefits from the Social Security Administration (SSA). Visit SSA web site for more specific information. 8.00 Skin Disorders 9.00 Endocrine Disorders 10.00 Impairments that Affect Multiple Body Systems 11.00 Neurological 12.00 Mental Disorders 13.00 Malignant Neoplastic Diseases 14.00 Immune Systems Disorders DFPR license verified: Month Day Year McLean 115 E Washington St Rm 101 PO Box 2400 Bloomington 61701 [PHONE REDACTED] Reset Print