Illinois Department of Revenue Afidavit for Hospital Property Tax Exemption — PTAX-300-HA (35 ILCS 200/15-10e) Step 1: Identify the property __________________________________________________ 1 7 Check the relevant hospital entity: Name of hospital or afiliate iling the afidavit ___ hospital owner - write the license number: ____________________ 2 __________________________________________________ ___ hospital afiliate - explain relationship: _______________________ Street address of hospital or afiliate ___ hospital system - explain relationship: _______________________ ______________________________________IL __________ 8 Property index numbers (PIN) included in this afidavit. City ZIP ___________________________________________________ __________________________________________________ ___________________________________________________ 3 County in which property is located (Continue on back page.) 4 Provide the Department of Revenue Docket number for which 9 If the applicant has an Illinois sales tax exemption number, write this afidavit is being iled. _____________________________ it here. E — ___ ___ ___ ___ — ___ ___ ___ ___ 5 Write the assessment year for which this afidavit is being 10 Check what the value of services and activities below relect: iled. _______________ ____ hospital year ____average of 3 iscal years ending with hospital year 6 What is your iscal year? _________________ Step 2: Provide the following about the services and activities for the relevant hospital entity 11 Write the amount of charity care provided. 11 _________________ 12 Write the amount of unreimbursed costs for health services provided to low-income and underserved individuals. 12 _________________ 13 If the hospital gives a subsidy to a state or local government, write the total amount. 13 _________________ 14 If the hospital gives a subsidy for Illinois health care programs to low-income individuals, write the total amount. 14 _________________ 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 . 16 _________________ 17 The value of any other service or activity not reported above. 17 _________________ Clearly specify the service or activity: ____________________________________________________________ 18 Total-Add Lines 11 through 17. 18 __ 19 What is the total amount of property taxes, actual or estimated, for all the exempt property the owner, afiliate, or system, identiied on Line 7, owns for the tax year for which this afidavit is being submitted? 19 _________________ 20 Has the ownership or use of this property identiied on Line 8 changed from the prior year? 20 Yes No 21 Have there been any changes from the prior year with respect to the leasing of any of the properties identiied on Line 8? If yes, please explain and provide a copy of the rental agreement/lease. 21 Yes No ________________________________________________________________________________________ Step 3: Signature and notarization Under penalties of perjury, I state that, to the best of my knowledge, the information contained in this afidavit is true, correct, and complete. Subscribed and sworn to before me this ______________________________________ / / Signature Date day of , 20 . Contact phone number ____________________________________ _________________________________________ Email address ___________________________________________ Notary public Complete and submit this afidavit to the Chief County Assessment Oficer. --For county use only-- ___________________________________________________ _______/_______/______________ Authorized Signature of Chief County Assessment Oficer Date PTAX-300-HA front (N-10/14) = Page 1 = Instructions Step 1: Identify the property limited to, General Assistance, the Covering ALL KIDS Health Insurance Act, and the State Children’s Health Insurance Program; Lines 1-7 — Follow the instructions on the form. or Line 8 — List the property index numbers (PIN) included in this • the amount of subsidy provided by the Relevant Hospital Entity afidavit. If you need additional room to list multiple PINs, continue and any hospital afiliate designated by the Relevant Hospital below. Entity (provided that such hospital afiliate’s operations provide Line 9 — Follow the instructions on the form. inancial or operational support for or receive inancial or Line 10 — Check whether the igures for services and activities operational support from the Relevant Hospital Entity) to state or you will enter on Lines 11 through 21 are for the hospital year or the local government in treating Medicaid recipients and recipients average of the previous three iscal years ending with the hospital of means-tested programs, including but not limited to General year. Assistance, the Covering ALL KIDS Health Insurance Act, and the Hospital year - The iscal year of the relevant hospital entity, or the iscal State Children’s Health Insurance Program. year of one of the hospital owners in the hospital system if the relevant The amount of subsidy for purposes of the item is calculated in the hospital entity is a hospital system with members with different iscal years, same manner as unreimbursed costs are calculated for Medicaid that ends in the year for which the exemption is sought. and other means-tested government programs on federal Form 990, Schedule H. Unreimbursed costs shall be net of fee-for-services Step 2: Provide information about the services payments, payments pursuant to an assessment, quarterly payments, and activities for the relevant hospital entity and all other payments included on the Schedule H. Line 11 — Charity care — Free or discounted services provided Line 15 — Dual-eligible subsidy — This is the amount of subsidy pursuant to the Relevant Hospital Entity’s inancial assistance provided to the government by treating dual-eligible Medicare/ policy, measured at cost, including discounts provided under the Medicaid patients. The amount of subsidy is calculated by multiplying Hospital Uninsured Patient Act. the Relevant Hospital Entity’s ratio of dual-eligible patients to total Line 12 — Health services to low-income and underserved Medicare patients by the Relevant Hospital Entity’s unreimbursed costs individuals — Unreimbursed costs of the Relevant Hospital Entity for Medicare (calculated in the same manner as federal Form 990, for providing without charge, paying for, or subsidizing goods, Schedule H). activities, or services for the purpose of addressing the health of Line 16 — Relief of the burden of government related to health low-income or underserved individuals. Those activities or services care of low-income individuals — From Schedule A . may include, but are not limited to, inancial or in-kind support to Line 17 — Enter the value of any other activity by the hospital that afiliated or unafiliated hospitals, hospital afiliates, community the Department determines relieves the burden of government or clinics, or programs that treat low-income or underserved addresses the health of low-income or underserved individuals. Clearly individuals; providing or subsidizing outreach or educational specify the service or activity. services to low-income or underserved individuals for disease Line 18 — Add Lines 11-17 and enter the total here. management and prevention; free or subsidized goods, supplies, Line 19 — Write the amount of the actual property tax from the or services needed by low-income or underserved individuals property tax bill or the estimated property tax from Schedule E, Line because of their medical condition; and prenatal or childbirth 18, whichever is less, for all of the exempt property the owner, afiliate, outreach to low-income or underserved persons. or system owns for the year for which this afidavit is being submitted. Line 13 — Subsidy of state or local governments — Direct or From Schedule E. indirect inancial or in-kind subsidies of state or local governments by the Relevant Hospital Entity that pay for or subsidize activities Line 20 — Check yes or no if this property’s ownership or use has or programs related to health care for low-income or underserved changed. individuals. Line 21 — Check yes or no if there have been any changes from the Line 14 — Support for state health care programs for low- prior year with respect to the leasing of any of the properties identiied income individuals — At the election of the Hospital Applicant for on Line 8. If yes, enter a brief explanation and attach a copy of the each applicable year, either rental agreement or lease. • 10 percent of payments to the Relevant Hospital Entity and any Hospital Afiliate designated by the relevant Hospital Step 3: Signature and notarization Entity (provided that such hospital afiliate’s operations provide The afidavit must be signed under oath, verifying that all of the inancial or operational support for or receive inancial or information is true and correct to the best of the applicant’s knowledge operational support from the Relevant Hospital Entity) under and belief. This afidavit must be notarized before sending to the Medicaid or other means-tested programs, including, but not Chief County Assessment Oficer. 8 Additional Property index numbers (PIN) included in this ___________________________________________________ afidavit. ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ PTAX-300-HA back (N-10/14) = Page 2 =