Step-by-Step Instructions for Filing this Form
Page 3 (Rev. February 2016)
Part 1: Complete the following information
Application Data
─Type or print your name, address, and Driver’s
License or State ID number, date of birth, and phone number.
Lines 1 through 3
─Follow the instructions on the form.
Line 4
─Write the names, relationship to the applicant and date of
birth for all other individuals, including your spouse, who used
the property for their principal residence on January 1, 2016. Attach
an additional sheet if necessary.
Part 2: Complete the 2015 income information
for the entire household
“Income” for this exemption means 2015 federal adjusted gross
income, plus certain items subtracted from or not included in your
federal adjusted gross income. These include tax-exempt interest,
dividends, pensions, annuities, net operating loss carryovers,
capital loss carryovers, and Social Security benefits. Income also
includes public assistance payments from governmental agency,
Supplemental Security Income, and certain taxes paid. These step-
by-step instructions provide federal return line references and
reporting statement references, whenever possible. The amounts
written on each line must include your 2015 income and the income
of all the individuals living in the household.
Line 1─Social Security and Supplemental Security Income
(SSI) Benefits Write the total amount of any retirement, disability,
or survivor’s benefits (including Medicare deductions) the entire
household received from the Social Security Administration.
(Shown in box 5 of Form SSA-1099.) You must also include any
Supplemental Security Income (SSI) the entire household
received and any benefits to dependent children in the
household. Do not include reimbursements under
Medicare/Medicaid for medical expenses. Note: The amount
deducted for Medicare ($1,461.60 yearly or $121.80 per month,
per person) is already included in the amount in box 5 of Form
SSA-1099 (also shown on line 20a on the Federal 1040 or line
14a on the Federal 1040A).
Line 2─Railroad Retirement benefits Write the total amount of
any retirement, disability, or survivor’s benefits (including
Medicare deductions) the entire household received under the
Railroad Retirement Act (shown on Forms SSA-1099 and RRB-
1099).
Line 3─Civil Service benefits Write the total amount of any retire-
ment, disability, or survivor’s benefits the entire household
received under any Civil Service retirement plan (shown on Form
1099-R).
Line 4─Other pensions and annuity benefits Write the total
income the entire household received as an annuity, endowment,
life insurance contract or similar contract or agreement (shown on
Form 1099-R). Include only the federally taxable portion of IRAs,
IRAs converted to Roth IRAs, and pensions (shown on Federal
1040, Line 15b and 16b, Federal 1040 A, Line 11b and 12b).
IRAs are not taxable when “rolled over”, unless “rolled over” into
a Roth IRA.
Line 5─Human Services and other governmental cash public
assistance benefits Write the total amount of Human Services
and other governmental cash public assistance benefits the entire
household received. If the first two digits of any member’s
Human Services case number are the same as any of those in
the following list, you must include the total amount of any of
these benefits on Line 5.
01─aged 04 and 06─ temporary assistance to
02─blind needy families (TANF)
03─disabled 07─general assistance
To determine the total amount of the household benefits,
multiply the monthly amount each person received by 12. You
must adjust your figures accordingly if anyone in the household
did not receive 12 equal checks during this period. Food
stamps, medical assistance benefits anyone in the household
may have received are not considered income and should not
be added to your total income.
Line 6─Wages, salaries, and tips from work Write the total
amount of wages, salaries, and tips from work, for every
household member (shown in box 1 of form W-2).
Line 7─Interest and dividends received Write the total of all
interest and dividends the entire household received from all
sources, including any government sources (shown on Forms
1099-INT, 1099-OID, and 1099-DIV). You must include both
taxable and nontaxable amounts.
Line 8
─Net rental, farm, and business income or (loss) Write
the total amount of any net income or loss from rental, farm,
business sources, etc., the entire household received, as
allowed on Federal 1040, Lines 12, 17 and 18. Attach IRS
Schedule C, E and/or F to the application if you are
claiming a loss. You cannot use any net operating loss
(NOL) carryover in figuring income.
Line 9
─Net capital gain or (loss) Write the total amount of any
taxable capital gain or loss the entire household received in
2015, as allowed on Federal 1040, Lines 13 and 14, or Federal
1040A, Line 10. Attach IRS Schedule D to the application if
you are claiming a loss. You cannot use a net capital loss
carryover in figuring income.
Line 10
─Other income or (loss) Write the total amount of any
other income or loss not included in Lines 1 through 9 that is
included in federal adjusted gross income, such as alimony
received, unemployment compensation, taxes withheld from oil or
gas well royalties. You cannot use any net operating loss
(NOL) carryover in figuring income.
Line 11
─Add Lines 1 through 10.
Line 12─Subtractions You may subtract only the reported
adjustments to income totaled on Federal 1040 Line 36 or
Federal 1040A, Line 20:
Educator expenses
Health savings account deduction
IRA deduction
Student loan interest deduction
Tuition and fees deduction
Jury duty pay you gave to your employer
Archer MSA deduction
Moving expenses
Deductible part of self-employment tax
Self-employed health insurance deduction
Self-employed SEP, SIMPLE, and qualified plans
Penalty on early withdrawal of savings
Alimony or maintenance paid
Domestic production activities deduction
Line 13
─Total household income Subtract Line 12 from Line 11.
If this amount is greater than $55,000, you do not qualify for this
exemption.
Part 3: Complete this affidavit
Lines 1 through 6
─Read the affidavit carefully. Check any
statements that pertain to you; all statements must be marked.
Note: You must sign your application and this form must also
be notarized. Return your completed form to:
Kane County Assessment Office
Kane County Government Center, Building C
719 South Batavia Avenue
Geneva, Illinois 60134-3000