Appeal YearCertificate of Error Applicationfor Exempt Property Appeal NumberDO NOT file this form if the property does not qualify as exempt from property tax. Property Index Number(s) Property ClassFor Office Use Only Grant Deny Date (attach separate sheet for additional PINs) Reason for C/E (be specific) Signature of Owner/Lessee Date Zip State City Applicant's Street Address Applicant's Name Daytime Phone Number Signature of Representative Date Zip State City Representative's Street Address Representative's Name/Firm Name Daytime Phone Number FOR REPRESENTATIVE ONLY (IF APPLICABLE) Township C/E Year Page 1 of 3 COOK COUNTY ASSESSOR COOK COUNTY ASSESSORS OFFICE 118 NORTH CLARK STREET,CHICAGO, IL 60602 PHONE: 312.443.7550WWW.COOKCOUNTYASSESSOR.COM American LegalNet, Inc. www.FormsWorkFlow.com 5.Other: Appeal YearCertificate of Error Applicationfor Exempt Property Appeal Number TownshipDocument Schedule PINs:Check box if document is submitted. C/E Year 1.Affidavit(must submit an original and a copy of one of the following items:): Department of Revenue Letter or Department of Revenue Hearing Disposition Notice of Road Taking Department of Local Government Affairs Letter Court Order Memorandum from the Cook County Assessor's Office Legal Department Recorded Deed (if property transferred to a trust, then the assignment of the beneficial interest must also be submitted) Installment Agreement, Articles of Agreement or Contract of Sale Complaint to Condemn, Order Vesting Title and Final Judgement Order (include "Exhibit A" which contains the legal Plat of Dedication Other: Affidavit of Use Continuing Use Affidavit (if this is submitted, then a copy of the applicable division must also be included.)2.Proof of Ownership(must submit two copies of one of the following items:):description of the property in question), and the receipt for the Condemnation Deposit (from the Treasurer's Office). 3.Administrative Decisions(must submit two copies of one of the following items:):4.Miscellaneous Division(if the Property Index Number is different on any of the documents submitted) Block cover (if there is an older division, multiple divisions, or if copy of division is not available) Lease agreement (or Court Order for Eviction) Amendment to the Articles of Incorporation changing the name (if organization's current name is different than what is listedon the other documents submitted)Page 2 of 3 COOK COUNTY ASSESSOR COOK COUNTY ASSESSORS OFFICE 118 NORTH CLARK STREET,CHICAGO, IL 60602 PHONE: 312.443.7550WWW.COOKCOUNTYASSESSOR.COM American LegalNet, Inc. www.FormsWorkFlow.com Document ScheduleCertificate of Error Applicationfor Exempt Property Page 3 of 3 Notary Stamp Signature of Affiant* Property Street Address City State Zip Daytime Phone Number*This Affidavit must be signed by someone who has personal knowledge of the property at the time in question.And further this affiant sayeth not. (Affiant's Name) (Title in Organization)ofbeing first duly sworn deposes and says that: (Name of Organization) (list below Property Index Numbers as listed on the Department of Revenue Letter) (Address, City, State, Zipcommonly known aswas acquired on by (Date) (Type of Document (attached)) (Date)and further states that said property was used fromto (Date) as(state use of property) Signature of * Subscribed and sworn before me this day of , 20 COOK COUNTY ASSESSOR COOK COUNTY ASSESSORS OFFICE 118 NORTH CLARK STREET,CHICAGO, IL 60602 PHONE: 312.443.7550WWW.COOKCOUNTYASSESSOR.COM American LegalNet, Inc. www.FormsWorkFlow.com