RECEIVED AND CHECKED BY:Name of Taxpayer / Owner Address Email1CityStateZip CodePhone23OwnerFormer Owner Liable for TaxTenant Liable for TaxExecutorBeneficiary of Trust4Other (Explain)5678Appeal Type:Current Year Appeal OnlyCurrent Year & C of E C of E OnlyTaxableExExempt9Street Address10CityTownship1112DATA SUBMITTED WITH APPEALDATA TO BE SUBMITTED1314CommercialIndustrialNot for ProfitCondoOver 6 Apartments15Mixed UseOther (Explain)16FIELD CHECK REQUEST If purchased on or after January 1, 20, indicate year purchased and purchase price. If purchased prior to January 1, 20 insert "prior".YearPurchase Price If yes, attach explanationSignature of Taxpayer or Attorney / RepresentativeATTORNEY/REPRESENTATIVE CERTIFICATION: IATTORNEY / REPRESENTATIVE NAME (PRINT OR TYPE)FIRM / COMPANY NAMEcertify that I have obtained fromFIRM / COMPANY ADDRESSCITYZIPPHONE (1) explicit authorization to file this 201 assessment appeal and/or Certificate of Error and (2) the Taxpayers assurance that I am the only attorney/Representative so authorized.Attorney / Representative Fax NumberAttorney / Representative Signature and Code Numbere-mail AddressOffice Hours: 8:30 A.M.- 5:00 P.M. 201 Real Estate Assessed Valuation Appeal 1How is the Subject Property used? Check all that apply.2Select one: NATURE OF APPEAL - LOCATION AND IDENTIFICATION OF REAL ESTATE PLEASE COMPLETE ALL PARTS OF THE APPEAL FORM. TYPE OR PRINT ALL INFORMATION. COMPLY WITH ASSESSORS OFFICE RULES AND REGULATIONS IN FILLING OUT AND FILING THIS FORMDO NOT LIST COMPARABLES BELOW IDENTIFICATION AND STATUS OF OWNER / TAXPAYERList in ascending order all Permanent Index Numbers associated with the subject property. SUBJECT PROPERTY PERMANENT INDEX NUMBER(S)CERTIFICATE OF ERROR YEAR(S)THIS FORM MUST BE FILED IN DUPLICATE. FILE BOTH COPIES WITH COOK COUNTY ASSESSOR'S OFFICE - RETAIN TIME STAMPED COPY FOR YOUR RECORDS YOU WILL BE NOTIFIED BY MAIL OF THE APPEAL NUMBER. YOU CAN FIND YOUR APPEAL NUMBER AND CHECK APPEAL STATUS ONLINE @ www.cookcountyassessor.comLocation of Subject Property:The undersigned states that he/she has read the above appeal, has personal knowledge of the contents thereof, and the same is true in substance and in fact and further so certifies under the penalties as provided by law pursuant to section 1-109 of the Illinois Code of Civil Procedure. NOTE: FAILURE TO FILE OWNER / LESSEE AFFIDAVIT MAY RESULT IN DENIAL OF THIS APPEAL.NOYESLIST ADDITIONAL INDEX NUMBERS ON ANOTHER APPEAL FORMNOTICE TO FILERS:3ATTORNEY / REPRESENTATIVE ONLYTAXPAYER NAMETAXPAYER TITLE OR POSITIONCook County Assessor's Office Cook County Assessor COOK COUNTY ASSESSOR APPEAL NUMBERIND. / COMM.I/C118 N. Clark Street - 3rd FloorChicago, Illinois 60602 American LegalNet, Inc. www.FormsWorkFlow.com 201201