I.

Background Information

A.

Name of the Petitioner:

Principal office address:

Telephone:  (Area Code)

B.

Name of Petitioner’s Representative

Title:

Office Address:

Phone:

Area Code:

C.

Check the Petitioner’s status:

1.

Municipality

4.

School District

2.

County

5.

Community College Dis-

3.

Township

6.

Other

Specify:

II.

Description of the Mandate

A.

Describe the mandate in question:

B.

Check the source of the mandate and provide the correct citation.

1.

Statutory:

2.

Executive Order:

3.

Administrative Rule:

C.

When did the mandate first become effective?

D.

Check the type of mandate which you believe is involved:

1.

Local government organization and structure mandate, as defined in 3 (c) of the Act;

2.

Due process mandate, as defined in 3(d) of the Act;

3.

Service mandate, as defined in 3(g). If so complete the following:

(a)

Is there any program of State aid for the service required by the mandate?

Yes

No

If yes,

(1)

Provide the name of the program:

(2)

Is non-local share 50% or more?

Yes

No

(3)

Are the increased costs allowable expenditures under the aid program?

Yes

No

On what do you base your determination?

(4)

Is all or part of the net increase in cost resulting from the mandate met by:

(a)

Federal financial assistance:

Yes

No

(b)

Other external financial sources:

Yes

No

(c)

If (4) (a) or (b) is yes, how much?

$________________________

4.

Tax exemption mandate as defined in 3(g).

If so, complete the following:

a.

Does the appeal involve a loss of tax revenue?

Yes

No

If yes:

(1)

Does that loss of revenue result from a loss of tax base?

Yes

No

If yes:

(a)

Describe the type of property involved in the classification or exemption which causes tax base loss.

1.

Real property

2.

Personal property

3.

Other – specify:

(b)

Was this type of property assessed for real estate tax purposes January 1, 1980?

Yes

No

If yes, state:

1.

Value for tax purposes of the property reclassified or made exempt by the mandate.

2.

The tax rate extended against such property in the latest year in which collection* was made.

3.

The rate of collection in the latest year in which collection was made.

4.

The revenue lost due to the mandate in the latest year in which collection was made.  $_________________

5.

The projected loss of revenue due to the mandate for the current collection year.  $__________________

*For the purpose of this Section 4(b)2, the word “collection” shall be deemed to mean the “issuance of final tax bills for the year in question”.

5.

Personnel mandate as defined in 3(h) of the Act. If so, check which of the following are involved:

a.

Salaries and wages

b.

Employee qualifications

c.

Employee training

d.

Hours

e.

Location of employment

f.

Other working conditions

g.

Insurance

h.

Health

i.

Medical care

j.

Retirement. If checked, document the extent to which such

employee retirement benefits will be involved.

k.

Other benefits. If checked, describe in detail:

III.

Reimbursement Standards

A.

State the increase in cost directly attributable to the mandate from the effective

of the mandate to the first June 30th following the effective date:

Provide supporting documentation for III A and B and basis for estimates, if any, as an exhibit.

B.

State the increase in cost directly attributable to the mandate from the 1st to the 2nd

June 30th following the effective date:

Provide supporting documentation for III A and B and basis for estimates, if any, as an exhibit.

C.

Did Petitioner or any entity in which petitioner was a member provide all or any portion of the mandated services prior to the effective date of the mandate?

Yes

No

If yes:

(1)

Please describe the extent and manner in which the services were provided and the cost of those services.

(2)

State whether the Petitioner has or is prepared to reduce real property taxes commensurately?

Yes

No

D.

Was the mandate:

(1)

Adopted at the request of the Petitioner?

Yes

No

(2)

Adopted at the request of an organization in which the Petitioner is a member?

Yes

No

(3)

Can the additional duties be carried out by the existing staff and procedures?

Yes

No

(a)

If yes, can they be done at no appreciable cost increase?

Yes

No

(b)

Does the mandate provide any offsetting savings?

Yes

No

(i)

If yes, indicate the amount of these savings

(4)

Does the mandate impose additional net annual cost increases of $1,000.00 or more for the Petitioner?

(5)

Does the mandate impose additional net costs of $50,000.00 or more for all local governments affected?

Yes

No

(6)

If any of the preceding paragraphs (1) – (5) were answered Yes, did the law imposing the mandate explicitly state that exception?

Yes

No

E.

Has the State of Illinois appropriated funds to reimburse local government for this mandate?

Yes

No

(1)

If yes, please identify the public act number:

F.

Provide the date on, and name of agency to which, a claim for reimbursement accompanied by estimate of increased costs for the balance of the fiscal year was filed

(1)

Date:

(2)

Name:

G.

Is information submitted in that estimate accurate, based on actual performance records?

Yes

No

(1)

If no, provide correct information as an exhibit.

(2)

If yes, provide documentation as an exhibit.

H.

Have claims of this type been subject to a proportional reduction because insufficient funds were appropriated?

Yes

No

If yes, state:

(1)

Amount claimed:

(2)

Amount allowed by the Dept.

(3)

Amount awarded:

I.

Please describe in detail the extent to which the mandate has been carried out in an effective and efficient manner.(Provide supporting documentation as an exhibit.)

J.

Does the mandate statute specify standards of staffing or expenditure limitations as described in Section 8(3) (d) of the Act?

Yes

No

(1)

If yes, please indicate in detail how the mandate has been carried out without recourse to standards of staffing or expenditure higher than specified in the statute. Provide supporting documentation as an exhibit, if necessary.

K.

Please indicate the relief sought from the Mandates Board of Appeals:

Petitioner, By:

Representative

Acknowledgement

I,

, certify that I have read the foregoing appeal petition and

supporting documentation and exhibits, and believe the same to be true in substance and in fact.

Subscribed and sworn to before me

this

day of

, 19

Notary Public