I certify all information on this form and any attached statements, schedules, etc., are true and correct to the best
of my knowledge as of January 1 of this year.
The property appraiser may require additional information to determine your eligibility for the exemption requested.
B. Hospitals, Nursing Homes,
and Homes for Special
Services
Organizations filing for exemption under this category must include the following
information in addition to completing sections A & D.
1. Did you possess a valid license under Chapters 395, 400, or part I of Chapter 429, Florida Statutes, on January 1
of this year? Yes No
2. Have you qualified under Section 501(c)(3), United States Internal Revenue Code 1954? Yes No
C. Affordable Housing /
Multi-Family Affordable Housing
Organizations filing for exemption under this category must include the
following information in addition to completing sections A & D.
1. How many units are used to provide affordable housing?
2. As of January 1, have there been at least 15 completed years of the recorded agreement terms on the
portion of the affordable housing property for extremely-low, very-low, or low-income limits? Yes No
3. Is the property subject to an agreement with the Florida Housing Finance Corporation? Yes No
4. Is the agreement recorded in the official records of the county? Yes No
You must attach the following information except when applying for exemption as
an educational institution.
Every attachment must show the name and address of the organization, the date, and an identifiable heading
and indicate that it is an attachment to Form DR-504.
1. If incorporated, a copy of your articles of incorporation
If not incorporated, a copy of your constitution, articles of association, declaration of trust, or other document
setting your aims and purposes, including any amendments
2. A statement indicating the salaries, fees, loans, commissions, gratuities, or other compensation of any
officer, director, trustee, member, or stockholder of this organization.
3. A statement indicating the guarantee of any loan to or obligation of any officer, director, trustee, member, or
stockholder of this organization.
4. Any contracts between the applicant and any officer, director, trustee, member, or stockholder of this
organization pertaining to:
a. rendition of service
b. provision of goods or supplies
c. the management of the applicant
d. the construction or renovation of the applicant
5. A schedule of the following:
a. salaries for the operation of the applicant
b. services rendered to the applicant
c. supplies and materials used by the applicant
d. reserves for repair, replacement, and depreciation of the property of the applicant
e. mortgage, lien, and encumbrance payments for the property of the applicant
6. A statement indicating the amounts the applicant charged for its services.
7. A statement indicating to what degree the proceeds of the sale, lease, or other disposition of the applicant’s
property will inure to the benefit of the organization’s members, directors, or officers.
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