JOSEPH BERRIOS WWW.COOKCOUNTYASSESSOR.COM Certificate of Error Application for Exempt Property 2010 Appeal Year Appeal Number Township C/E Year DO NOT file this form if the property does not qualify as exempt from property tax. Property Index Number(s) Property Class For Office Use Only Grant Deny Date (attach separate sheet for additional PINs) Reason for C/E (be specific) Applicant's Name Signature of Owner/Lessee Applicant's Street Address Date City State Zip Daytime Phone Number FOR REPRESENTATIVE ONLY (IF APPLICABLE) Representative's Name/Firm Name Signature of Representative Representative's Street Address Date City 1101122210 COOK COUNTY ASSESSOR'S OFFICE 118 NORTH CLARK STREET, CHICAGO, IL 60602 PHONE: 312.443.7550 FAX: 312.603.3352 COOK COUNTY ASSESSOR State Zip Daytime Phone Number Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com JOSEPH BERRIOS WWW.COOKCOUNTYASSESSOR.COM Appeal Year Certificate of Error Application for Exempt Property C/E Year Document Schedule 2010 1102122210 COOK COUNTY ASSESSOR'S OFFICE 118 NORTH CLARK STREET, CHICAGO, IL 60602 PHONE: 312.443.7550 FAX: 312.603.3352 COOK COUNTY ASSESSOR Appeal Number Township PINs: Check box if document is submitted. 1. Affidavit (must submit an original and a copy of one of the following items:): 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:): 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 description of the property in question), and the receipt for the Condemnation Deposit (from the Treasurer's Office). Plat of Dedication Other: 3. Administrative Decisions (must submit two copies 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 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 listed on the other documents submitted) 5. Other: Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com JOSEPH BERRIOS WWW.COOKCOUNTYASSESSOR.COM 1103122210 COOK COUNTY ASSESSOR'S OFFICE 118 NORTH CLARK STREET, CHICAGO, IL 60602 PHONE: 312.443.7550 FAX: 312.603.3352 COOK COUNTY ASSESSOR Certificate of Error Application for Exempt Property Document Schedule (Affiant's Name) (Title in Organization) of being first duly sworn deposes and says that: (Name of Organization) (list below Property Index Numbers as listed on the Department of Revenue Letter) commonly known as (Address, City, State, Zip was acquired on by (Date) (Type of Document (attached)) and further states that said property was used from to (Date) (Date) as (state use of property) And further this affiant sayeth not. Signature of Affiant* Property Street Address Daytime Phone Number City State Zip *This Affidavit must be signed by someone who has personal knowledge of the property at the time in question. Subscribed and sworn before me this day of , 2 0 Notary Stamp Signature of Affiant* Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com