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DR-501SC, R. 12/12
Rule 12D-16.002, F.A.C.
ADJUSTED GROSS HOUSEHOLD INCOME
SWORN STATEMENT AND RETURN
Senior Citizen Exemption for Persons Age 65 and Over
Section 196.075, Florida Statutes Application year 20
This statement must be filed each year with the property appraiser by March 1. Initial Renewal*
PART 1 List all persons living in the homestead on January 1 the year of exemption.
Do not include
renters or boarders
Total adjusted gross income for all household members
For each household member, submit the documents required by either PART 2 or PART 3 for last year’s income.
*If you are renewing your exemption, you do not need to submit documents, unless the property appraiser asks. Contact your property
appraiser’s office for instructions.
PART 2 For each member who files an IRS Form 1040 series (checked “Yes” in PART 1), submit:
IRS 1040 series form or an Application for Automatic Extension of Time to File U.S. Individual Income Tax
Return (Form 4868), if applicable, and
Wage and Tax Statements (W-2 Forms).
PART 3 For each member who does not file an IRS Form 1040 series (checked “No” in PART 1), submit:
A copy of the prior year's Social Security Statement (SSA 1099), if applicable,
An IRS Request for Transcript of Tax Return, IRS Form 4506-T. (Form 8821 or another form from the 4506
series can substitute), and
A Statement of Income from page 2 of this form.
For prompt consideration, submit supporting documents by May 1. No further documentation will be accepted after June 1.
If additional documents are required, the property appraiser will ask for them.
I certify that:
I am at least 65 years old on January 1 of the tax year I am applying for. I have attached proof of my age.
The total prior year adjusted gross income of all persons living in the household on January 1 of the tax year is not
more than the adjusted gross income in section 62 of the US Internal Revenue Code.
Contact your county property appraiser for the maximum household adjusted gross income, which may change each year.
I qualify for this exemption under Florida law. I am a permanent resident of the State of Florida and I own and occupy the
property above. Under s. 196.131(2), F.S., any person who knowingly and willfully gives false information to claim
homestead exemption is guilty of a misdemeanor of the first degree, punishable by a term of imprisonment up to 1 year or
a fine up to $5,000 or both. Under penalties of perjury, I declare that I have read this application and Statement of
Adjusted Gross Income and the facts in it are true.
____________________________________________ ________________________ _________
Signature, applicant Print name Date
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