Schedule A Calculation of Low-Income Portion of Unreimbursed Costs (PTAX-300-H Schedule A) is the worksheet a hospital attaches to Form PTAX-300-H when it applies for a property tax exemption. It is one of the Sangamon County property tax exemption forms handled through the Sangamon County Supervisor of Assessments. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the form itself is published by the county at the official URL below.
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What is PTAX-300-H Schedule A?
Schedule A Calculation of Low-Income Portion of Unreimbursed Costs is the supplemental worksheet, printed as PTAX-300-H Schedule A (R-02/13), that a hospital attaches to Form PTAX-300-H to work out how much of its unreimbursed costs went to benefiting low-income individuals.
The calculation has three steps. Step 1 (lines 1 to 11) totals the unreimbursed costs of services such as emergency, trauma, burn, neonatal, psychiatric and rehabilitation care, medical education and research, plus two lines for other costs you describe. Step 2 (lines 12 to 21) builds the low-income ratio from gross charges for charity care, Medicaid, other means-tested programs, disabled Medicare patients under 65 and dual-eligible patients, divided by total gross charges, with each side converted to costs by a cost to charge ratio. Step 3 (line 22) multiplies the Step 1 total by the ratio, and the result is written on Form PTAX-300-H, Line 17.
The general instructions printed on the schedule say the cost to charge ratio comes from the most recently filed Medicare cost report (CMS 2552-10 Worksheet C, Part 1). They refer to the hospital as the Relevant Hospital Entity.
The Sangamon County Supervisor of Assessments page lists this schedule, together with Schedule E, as a supplement to Form PTAX-300H for hospitals. It is not an application on its own and it is not a homestead exemption form.
Who needs to file PTAX-300-H Schedule A?
Hospitals that apply for a property tax exemption on Form PTAX-300-H complete this schedule and attach it to that form. The Sangamon County Supervisor of Assessments page states that hospitals use form PTAX-300H and the supplemental forms Schedule A and Schedule E.
The schedule measures the Relevant Hospital Entity's unreimbursed costs for services that relieve the burden of government related to health care for low-income individuals, so it is completed by the hospital entity or its agent preparing the application.
Other applicants use different forms, according to the county page:
- Organizations that are not hospitals, religious organizations or federal or state agencies use form PTAX-300.
- Religious organizations use form PTAX-300R.
- Federal and state agencies use form PTAX-300FS.
- The annual affidavit for hospitals is form PTAX-300HA.
Owner-occupied homeowners applying for homestead exemptions do not use this schedule.
When to file PTAX-300-H Schedule A
Complete Schedule A when you prepare Form PTAX-300-H, because the schedule is attached to that form and travels with the application. It prints no due date of its own. The result of line 22 must be written on Form PTAX-300-H, Line 17, so finish this schedule before you complete that line.
The deadlines the Sangamon County Supervisor of Assessments lists on its exemptions page, such as January 31 and July 1, belong to the homestead exemptions and do not apply to this schedule. For the timing of a hospital application, check Form PTAX-300-H and its instructions or ask the Board of Review.
Documents you need
- Form PTAX-300-H: Schedule A is attached to it, and the line 22 result is written on its Line 17.
- Most recently filed Medicare cost report (CMS 2552-10 Worksheet C, Part 1): the source of the cost to charge ratio you enter on lines 19 and 20. The schedule does not say to attach the report itself.
How to fill out PTAX-300-H Schedule A
Confirm the schedule goes with PTAX-300-H
Schedule A is attached to Form PTAX-300-H. Have that application and your most recently filed Medicare cost report (CMS 2552-10 Worksheet C, Part 1) ready.
Enter unreimbursed costs, lines 1 to 8
In Step 1, write the total of unreimbursed costs for Emergency (line 1), Trauma (2), Burn (3), Neonatal (4), Psychiatric (5), Rehabilitation (6), Medical education (7) and Research (8).
Describe other costs, lines 9 and 10
Use the two Other (describe) lines for any further unreimbursed costs, and write what each one is.
Add the total on line 11
Add lines 1 through 10 and enter the result on line 11.
Enter gross charges, lines 12 to 16
In Step 2, enter gross charges for Charity (line 12), Medicaid (13), Other means-tested programs (14), Disabled Medicare for people less than 65 years of age (15) and Dual-eligible (16).
Complete the numerator and denominator
Line 17: add lines 12 through 16; this is your numerator. Line 18: enter total gross charges; this is your denominator.
Apply the cost to charge ratio
On line 19, multiply line 17 by the cost to charge ratio and, on line 20, multiply line 18 by it. Take the ratio from the most recently filed Medicare cost report; for emergency services, use the costs of patients treated in the entity's emergency department.
Calculate the low-income ratio
Line 21: divide line 19 by line 20. The result is the low-income ratio.
Determine the low-income portion
In Step 3, line 22: multiply line 11 by line 21. Write this amount on Form PTAX-300-H, Line 17.
Review and download the completed PDF
Check every line and the arithmetic, then download or print the completed PDF from FillingPDF and attach it to Form PTAX-300-H as described under How to submit.
How to submit PTAX-300-H Schedule A
Schedule A is not filed by itself: it goes in the package with Form PTAX-300-H, which the organization files with the Board of Review.
- Board of Review: the Sangamon County page says organizations apply for property tax exemption with the Board of Review, which reviews the application and forwards it to the Illinois Department of Revenue for the final administrative decision. All applications and their corresponding documentation must be filed in duplicate.
- Forms in person: application forms are available at the Supervisor of Assessments office, 1st Floor of the Sangamon County Complex. Office hours are 8:30 am to 5:00 pm, Monday through Friday, except legal holidays when the County Complex is closed.
- Proof of filing: if a file stamped copy is not offered, the property owner or their agent should request one.
The schedule prints no separate address or portal. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Filing Schedule A without Form PTAX-300-H; the schedule says to attach it to that form.
- Forgetting to write the line 22 result on Form PTAX-300-H, Line 17, where the schedule directs it.
- Entering gross charges on lines 19 and 20 instead of multiplying lines 17 and 18 by the cost to charge ratio.
- Taking the cost to charge ratio from anywhere other than the most recently filed Medicare cost report (CMS 2552-10 Worksheet C, Part 1).
- Not limiting the emergency services ratio to costs of patients treated in the entity's emergency department, as the instructions require.
- Dividing line 20 by line 19; line 21 is Line 19 divided by Line 20.
- Entering amounts on line 9 or 10 without describing what the other costs are.
- Filing a single copy with the Board of Review when the county page requires applications and documentation in duplicate.
Frequently asked questions
What is PTAX-300-H Schedule A used for?
It calculates the low-income portion of a hospital's unreimbursed costs. The hospital totals its unreimbursed costs, figures a low-income ratio from gross charges and a cost to charge ratio, multiplies the two, and writes the result on Form PTAX-300-H, Line 17.
Which Sangamon County property tax exemption forms do hospitals use?
The Sangamon County Supervisor of Assessments says hospitals use form PTAX-300H with the supplemental forms Schedule A and Schedule E. The annual affidavit is form PTAX-300HA. Other organizations use PTAX-300, PTAX-300R or PTAX-300FS.
Where do I write the result of line 22?
Write the line 22 amount on Form PTAX-300-H, Line 17. Line 22 is line 11 multiplied by line 21, so complete Steps 1 and 2 first.
Where does the cost to charge ratio come from?
The instructions on the schedule say to take it from the most recently filed Medicare cost report (CMS 2552-10 Worksheet C, Part 1). For emergency services, use the costs of patients treated in the entity's emergency department.
Is there a separate deadline for Schedule A?
No deadline is printed on the schedule. It is attached to Form PTAX-300-H and is submitted with that application. The January 31 and July 1 dates on the county page apply to homestead exemptions, not to this schedule.
Where do I file Schedule A?
With Form PTAX-300-H at the Board of Review, according to the Sangamon County page. Applications and documentation must be filed in duplicate, and the Board forwards the application to the Illinois Department of Revenue for the final decision.
Can I fill out Schedule A online?
You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not file the schedule or the application; you submit it through the Board of Review.
Where can I get the exemption forms in person?
At the office of the Supervisor of Assessments on the 1st Floor of the Sangamon County Complex. Hours are 8:30 am to 5:00 pm, Monday through Friday, except legal holidays when the Complex is closed.
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