Fillable ADJUSTED GROSS HOUSEHOLD INCOME SWORN STATEMENT, Senior Citizen Exemption (City of Lake Wales)

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ADJUSTED GROSS HOUSEHOLD INCOME SWORN STATEMENT, Senior Citizen Exemption (City of Lake Wales)

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BROWSE CITY OF LAKE WALES (FL) FORMS
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You may use this form to apply for the Senior Citizen Exemption for persons 65 and Over. Your application should be
filed by March 1st and you must submit all required documentation by June 1st.
Your total combined household adjusted gross income cannot exceed the limitation determined annually by the
percentage change in the average cost-of-living index during the immediate prior year. The income limit for last year
was $28,
448. The income limit for this year will be available in mid-January.
If yo
u have questions or need assistance, please contact us.
Marsha Faux, CFA. ASA
Property Appraiser
DO YOU PREFER PAPERLESS COMMUNICATIONS WITH THE PROPERTY APPRAISER’S OFFICE?
Florida Statute 192.048 allows certain ad valorem communications to be sent electronically in lieu of first class mail. This service permits the flexibility of saving and
printing documents relating to your property at any given time. Should you wish to receive electronic communications from our office please sign below.
If an electronic notification is returned as undeliverable, the property appraiser will forward the document by regular mail.
NOTICE: Under Florida law, e-mail addresses are public records. By consenting to communicate with this office electronically, your e-mail address will be released in
response to any applicable public records request.
Owner Signature
Joint Owner Signature
Joint Owner Signature
Owner Name (Printed)
Joint Owner Name (Printed)
Joint Owner Name (Printed)
Owner e-mail address
Joint Owner e-mail address
Joint Owner e-mail address
Phone Number
Phone Number
Phone Number
Bartow Office
255 North Wilson Ave Bartow FL 33830
Ph: 863-534-4777 – Fax: 863-534-4753
Lakeland Office
930 E. Parker St. Suite 272 Lakeland FL 33801
Ph: 863-802-6150 – Fax: 863-802-6163
Winter Haven Office
3425 Lake Alfred Rd, 3 Gill Jones Plaza Winter Haven FL 33881
Ph: 863-401-2424 – Fax: 863-401-2428
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Page 1 of 2
DR-501SC, R. 12/12
Rule 12D-16.002, F.A.C.
Eff. 12/12
Provisional
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*
Parcel ID
Address
Applicant name
Phone
PART 1 List all persons living in the homestead on January 1 the year of exemption.
Do not include
renters or boarders
Name of Household Member
Date of Birth
Filed IRS return?
Yes No
Adjusted Gross
Income
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.
CERTIFICATION
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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Page 2 of 2
DR-501SC
R. 12/12
Page 2
INSTRUCTIONS
This exemption applies only to the property taxes of the taxing authority granting the exemption. To qualify for
an additional homestead exemption under s. 196.075, F.S. for persons age 65 years or older, the household
income of all persons living in the home cannot be more than the household adjusted gross income defined
below.
As used on this application, the term:
“Household” means a person or group of persons living together in a room or group of rooms as a
housing unit, but the term does not include persons boarding in or renting a portion of the dwelling.
“Household income” means the adjusted gross income in s. 62 of the US Internal Revenue Code, of all
members of a household. (This is the “Adjusted Gross Income” amount reported on IRS Form 1040.)
Definitions: Section 196.075, Florida Statutes
Examples of Supporting Documentation for the Property Appraiser
IRS Returns
Income Statements
Earning Statements
Form 1040
Form 1040A
Form 1040EZ
Social security benefits
Pension
Interest or annuities
Rental receipts
W-2 forms
RRB 1042S
SSA 1042S
Partnership income (1065)
Form 1099 Form
1099A RRB 1099
SSA 1099
For prompt consideration, submit income documentation before May 1 for all household members.
No documentation can be accepted after June 1.
Supporting documentation will be destroyed after use unless you ask the property appraiser to return the documents.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Complete this form for each member whose income is below the filing thresholds for the IRS and who has
not filed an IRS Form 1040 series. See page 1, PART 3. Do not complete for minor children with no income.
STATEMENT OF INCOME
Name
Earned income
Social Security benefits**
Investment income
Veterans Administration benefits
Capital gains or (losses)
Income from retirement plans
Interest income
Income from pensions
Rents
Income from trust funds
Royalties
Other*** (specify):
Dividends
Annuities
Total income for this household member
Enter this amount in PART 1 and submit with page 1 of Form DR-501SC for each member.
**Social Security Benefits - Internal Revenue Service (IRS) Information
According to the IRS, social security benefits include monthly survivor and disability benefits. They do not include
supplemental security (SSI) payments, which are not taxable.
If your combined benefits and other income exceed certain thresholds, some part of your Social Security income
may be taxable. Include the taxable amount on this line. Consult the IRS for Social Security income that may be
taxable based on current formulas.
***Other income
If you receive any other income, fill in the source and the amount. Do not include income that would not be
included in adjusted gross income, such as child support.
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ADJUSTED GROSS HOUSEHOLD INCOME SWORN STATEMENT, Senior Citizen Exemption (City of Lake Wales)

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Completed 22 August 2020

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