Fill - Free fillable Disabled Persons and Surviving Spouses PDF form

FOR COUNTY AUDITOR’S USE ONLY:

Taxing district and parcel or registration number Auditor’s application number

First year for homestead exemption

Date ﬁ led

Name on tax duplicate

Taxable value of homestead: Taxable land Taxable bldg. Taxable total

Method of Veriﬁ cation (must complete one):

Tax commissioner portal: Year Total OAGI No information returned

Ohio tax return (line 3): Year Total OAGI

Federal tax return (line 4, 1040EZ): Year Total FAGI

(line 21, 1040A): Year Total FAGI

(line 37, 1040): Year Total FAGI

Worksheet (attached): Estimated OAGI

Granted Denied

County auditor (or representative) Date

DTE 105A

Rev. 9/16

Homestead Exemption Application for Senior Citizens,

Disabled Persons and Surviving Spouses

Real property: File with the county auditor on or before Dec. 31.

Manufactured or mobile homes: File with the county auditor on or before the ﬁ rst Monday in June.

Please read the instructions on the back of this form before you complete it. Disabled applicants must complete form DTE 105E,

Certiﬁ cate of Disability for the Homestead Exemption, and attach it or a separate certiﬁ cation of disability status from an eligible state or

federal agency to this application. See Late Application in the instructions on page 3 of this form.

Current application

Late application for prior year

Application of person who received homestead reduction for 2013 or for 2014 for manufactured or mobile homes. Form DTE 105G

must accompany this application.

Application of person who received the homestead reduction for 2006 that is greater than the reduction calculated under the current law.

Form DTE 105G must accompany this application.

Type of application:

Senior citizen (must be at least age 65 by Dec. 31st of the year for which the exemption is sought)

Disabled person (must be permanently and totally disabled on Jan. 1 of the year for which exemption is sought)

Surviving spouse (must have been at least 59 years old on the date of the spouse’s death and must meet all other homestead exemp-

tion requirements)

Type of home:

Single family dwelling Unit in a multi-unit dwelling Condominium Unit in a housing cooperative

Manufactured or mobile home Land under a manufactured or mobile home

Applicant’s name Applicant’s date of birth SSN

Name of spouse Spouse’s date of birth SSN

Home address

County in which home is located

Taxing district and parcel or registration number

from tax bill or available from county auditor

- 1 -

In order to be eligible for the homestead exemption, the form of ownership must be identiﬁ ed. Property that is owned by a corporation,

partnership, limited liability company or other legal entity does not qualify for the exemption. Check the box that applies to this property.

The applicant is:

an individual named on the deed

a purchaser under a land installment contract

a life tenant under a life estate

a mortgagor (borrower) for an outstanding mortgage

trustee of a trust with the right to live in the property

the settlor, under a revocable or irrevocable inter vivos trust, holding title to a homestead occupied by the settlor as a right under the

trust

a stockholder in a qualiﬁ ed housing cooperative. See form DTE 105A – Supplement for additional information.

other

If the applicant or the applicant’s spouse owns a second or vacation home, please provide the address and county below.

Address City State ZIP code County

Have you or do you intend to ﬁ le an Ohio income tax return for last year? Yes No

Total income for the year preceding year of application, if known (see instructions):

I declare under penalty of perjury that (1) I occupied this property as my principal place of residence on Jan. 1 of the year(s) for which I

am requesting the homestead exemption, (2) I currently occupy this property as my principal place of residence, (3) I did not acquire this

homestead from a relative or in-law, other than my spouse, for the purpose of qualifying for the homestead exemption, (4) my total income

for myself and my spouse for the preceding year is as indicated above and (5) I have examined this application, and to the best of my

knowledge and belief, this application is true, correct and complete.

I (we) acknowledge that by signing this application, I (we) delegate to both the Ohio tax commissioner and to the auditor of the county in which the

property for which I am seeking exemption is located, and to their designated agents, the authority to release my tax and/or ﬁ nancial records and

to examine and consult regarding such records for the purpose of determining my eligibility for the homestead exemption or a possible violation of

the homestead laws. Such records shall not contain any federal tax information as deﬁ ned in I.R.C. 6103 and received from the Internal Revenue

Service. I expressly waive the conﬁ dentiality provisions of the Ohio Revised Code, including O.R.C. 5703.21 and 5747.18, which may otherwise

prohibit disclosure, and agree to hold the Ohio tax commissioner and county auditor harmless with respect to the limited disclosures herein. Except

as authorized by law, the parties to which this authority is delegated shall maintain the conﬁ dentiality of the information received and the information

shall not otherwise be re-disclosed.

Signature of applicant Signature of spouse

Mailing address Date

Phone number E-mail address

DTE 105A

Rev. 9/16

- 2 -

Mike Kovack, Medina County Auditor

144 North Broadway Street

Medina, OH 44256

(330) 725-9754 (844) 722-3800

www.medinacountyauditor.org

Individuals who received the homestead exemption for tax year 2013 (2014 for manufactured and mobile homes) on any

residence may continue to receive the homestead exemption on another residence within the state without meeting the

income test currently required for the exemption, if a different residence otherwise meets the qualiﬁ cation of a homestead.

In order to assure that an applicant has previously received the homestead exemption for the aged or disabled, certain

information must be made available to the county auditor.

Applicant’s name

Applicant’s current home address

Taxing district and parcel or registration number of current home

County in which prior homestead was granted

Address for which prior homestead was granted

Taxing district and parcel or registration number of prior home

I declare under penalty of perjury that I was receiving the homestead exemption for tax year 2013 (2014 for manufactured

and mobile homes) on the property described in this addendum, and have examined this document and, to the best of my

knowledge and belief, it is true, correct and complete.

Signature of applicant Date

Mailing address

Phone number E-mail address

DTE 105G

Rev. 11/13

Addendum to the Homestead Exemption Application for

Senior Citizens, Disabled Persons and Surviving Spouses

For applicants who have previously received the homestead exemption under R.C. 323.152(A)(2)(b).

Mike Kovack, Medina County Auditor

144 North Broadway Street

Medina, OH 44256

(330) 725-9754 (844) 722-3800

www.medinacountyauditor.org

DTE 105A

Rev. 9/16

Please read before you complete the application.

What is the Homestead Exemption? The homestead exemp-

tion provides a reduction in property taxes to qualiﬁ ed senior or

disabled citizens, or a surviving spouse, on the dwelling that is that

individual’s principal place of residence and up to one acre of land

of which an eligible individual is an owner. The reduction is equal

to the taxes that would otherwise be charged on up to $25,000 of

the market value of an eligible taxpayer’s homestead.

What Your Signature Means: By signing the front of this form,

you afﬁ rm under penalty of perjury that your statements on the

form are true, accurate and complete to the best of your knowl-

edge and belief and that you are authorizing the tax commissioner

and the county auditor to review ﬁ nancial and tax information ﬁ led

with the state. A conviction of willfully falsifying information on this

application will result in the loss of the homestead exemption for a

period of three years.

Qualiﬁ cations for the Homestead Exemption for Real Property

and Manufactured or Mobile Homes: To receive the homestead

exemption you must be (1) at least 65 years of age during the

year you ﬁ rst ﬁ le, or be determined to have been permanently and

totally disabled (see deﬁ nition at right), or be a surviving spouse

(see deﬁ nition at right), and (2) own and have occupied your home

as your principal place of residence on Jan. 1 of the year in which

you ﬁ le the application. For manufactured or mobile home owners,

the dates apply to the year following the year in which you ﬁ le the

application. A person only has one principal place of residence;

your principal place of residence determines, among other things,

where you are registered to vote and where you declare residency

for income tax purposes. You may be required to present evidence

of age. If the property is being purchased under a land contract,

is owned by a life estate or by a trust, or the applicant is the mort-

gagor of the property, you may be required to provide copies of

any contracts, trust agreements, mortgages or other documents

that identify the applicant’s eligible ownership interest in the home.

If you are applying for homestead and did not qualify for the ex-

emption for 2013 (2014 for manufactured homes), your total in-

come cannot exceed the amount set by law. “Total income” is de-

ﬁ ned as the adjusted gross income for Ohio income tax purposes

(line 3 of Ohio income tax return) of the owner and the owner’s

spouse for the year preceding the year for which you are applying.

If you do not ﬁ le an Ohio income tax return, you will be asked to

produce a federal income tax return for you and your spouse. If

you do not ﬁ le a federal income tax return, you will be asked to pro-

duced evidence of income and deductions allowable under Ohio

law so that the auditor may estimate Ohio adjusted gross income.

Current Application: If you qualify for the homestead exemption

for the ﬁ rst time this year (for real property) or for the ﬁ rst time next

year (for manufactured or mobile homes), check the box for Current

Application on the front of this form.

Late Application: If you also qualiﬁ ed for the homestead exemption

for last year (for real property) or for this year (for manufactured or

mobile homes) on the same property for which you are ﬁ ling a cur-

rent application, but you did not ﬁ le a current application for that year,

you may ﬁ le a late application for the missed year by checking the

late application box on the front of this form. You may only ﬁ le a late

application for the same property for which you are ﬁ ling a current

application.

Deﬁ nition of a Surviving Spouse: An eligible surviving spouse

must (1) be the surviving spouse of a person who was receiving

the homestead exemption by reason of age or disability for the

year in which the death occurred, and (2) must have been at least

59 years old on the date of the decedent’s death.

Permanent Disability: Permanent and totally disabled means a

person who has, on the ﬁ rst day of January of the year for which

the homestead exemption is requested, some impairment of body

or mind that makes him/her unﬁ t to work at any substantially remu-

nerative employment which he/she is reasonably able to perform

and which will, with reasonable probability, continue for an indeﬁ -

nite period of at least 12 months without any present indication

of recovery, or who has been certiﬁ ed as totally and permanently

disabled by an eligible state or federal agency.

- 3 -

Attach this form to the homestead exemption application (form DTE 105A)

if the applicant is requesting the homestead exemption based on disability status.

Ohio Revised Code section 323.151: “ ‘Permanently and totally disabled’ means a person who has, on the ﬁ rst day of Janu-

ary of the year of application for reduction in real estate taxes, some impairment in body or mind that makes the person un-

able to work at any substantially remunerative employment that the person is reasonably able to perform and that will, with

reasonable probability, continue for an indeﬁ nite period of at least twelve months without any present indication of recovery

therefrom or has been certiﬁ ed as permanently and totally disabled by a state or federal agency having the function of so

classifying persons.”

To be completed by the applicant

Applicant’s name

Home address

To be completed by the physician, psychologist or state or federal agency representative.

In accordance with the above, I (we) hereby certify that was, as of Jan. 1, ,

and is now permanently and totally disabled according to the above deﬁ nition by virtue of physical disability or

mental disability.

License number and state issuing (Note: If reason for reduction is

mental disability, the physician or psychologist must hold an Ohio license.)

Physician (signature) Print name of person signing form

Psychologist (signature) Address (please print)

Agency (please print) City State ZIP code

If agency, signature and title of person completing the form Date

In lieu of having a physician or psychologist sign this form, the applicant may submit a statement from an eligible state or

federal agency that the applicant is permanently and totally disabled as deﬁ ned above. See the back page of this form for

more information on what constitutes acceptable proof of permanent disability.

DTE 105E

Rev. 2/16

Certiﬁ cate of Disability for the Homestead Exemption

Name of applicant

Mike Kovack, Medina County Auditor

144 North Broadway Street

Medina, OH 44256

(330) 725-9754 (844) 722-3800

www.medinacountyauditor.org

Acceptable and Unacceptable Proofs of Permanent and Total Disability

Physician’s Certiﬁ cate: Acceptable. An application based

on physical disability must include a certiﬁ cate signed by a

physician. An application based on mental disability must

include a certiﬁ cate signed by a physician or a psychologist

licensed to practice in Ohio. Note: A chiropractor is not a

“physician” for purposes of the Homestead Law.

Federal Agencies:

Social Security Administration (SSA): An SSA (or SSI)

form indicating that an applicant is “disabled” is acceptable.

The SSA only gives disability beneﬁ ts to those who are per-

manently and totally disabled.

Department of Veterans Affairs (VA): Veterans with a total

service-connected disability or veterans who are receiving

100% compensation for service-connected disabilities follow-

ing a determination of individual unemployability should ﬁ le

DTE form 105I and submit the documentation indicated by

that application. If a veteran does not qualify as an eligible

disabled veteran, but meets the deﬁ nition found in R.C.

323.151(D) (provided at the top of this form), the veteran

must have a doctor or qualifying psychologist complete this

form. No VA documentation reﬂ ects the statutory deﬁ nition

of permanent and total disability in R.C. 323.151(D).

Railroad Retirement Board (RRB): The RRB has two types

of disability pensions: (1) total and permanent disability and

(2) occupational disability. Only the “permanent and total

disability” pension is acceptable.

State Agencies:

Bureau of Workers Compensation: A determination of

“permanent and total disability” is acceptable. Other de-

terminations, such as “permanent and partial disability”

“temporary and total disability,” and “temporary and partial

disability” are not.

State Retirement Systems: Not acceptable. The Public

Employees Retirement System (PERS), the State Teachers

Retirement System and the School Employees Retirement

System (SERS), do not certify permanent and total disability.

While the State Highway Patrol Retirement System (HPRS)

and the Police and Firemen’s Disability and Pension Fund

(PFDPF) do certify individuals to be “permanently and totally

disabled” these determinations are job-speciﬁ c and do not

rule out the possibility of other substantially remunerative

employment using a different set of skills.

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