Fillable HOUSEHOLD INCOME SWORN STATEMENT AND RETURN (Florida)

Fill Online, Printable, Fillable, Blank HOUSEHOLD INCOME SWORN STATEMENT AND RETURN (Florida) Form

Use Fill to complete blank online FLORIDA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

HOUSEHOLD INCOME SWORN STATEMENT AND RETURN (Florida)

On average this form takes 12 minutes to complete

The HOUSEHOLD INCOME SWORN STATEMENT AND RETURN (Florida) form is 3 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 44 other fields

Country of origin: US
File type: PDF

BROWSE FLORIDA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
DR-501SC
R. 12/21
Rule 12D-16.002, F.A.C.
Provisional
Page 1 of 3
HOUSEHOLD INCOME
SWORN STATEMENT AND RETURN
S
enior Citizen Exemption for Persons Age 65 and Over
Section 196.075, Florida Statutes Application year 20
This form is for use by property owners as a sworn statement of adjusted gross household income to qualify for
the additional homestead exemption for property owners age 65 and older, with limited income.
When applying for the exemption for the first time, submit this completed statement, the Original Application for
Homestead and Related Tax Exemptions (Form DR-501,
incorporated by reference in Rule 12D-16.002, F.A.C.),
and all required attachments with the county property appraiser on or before March 1 of the current tax year.
Applicant name
Address
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?
Ye
s No
Adjusted Gross
Household
Income
Total adjusted gross household 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.
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, an
d
•
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,
• A
n IRS Request for Transcript of Tax Return, IRS Form 4506-T. (Form 8821 or another form from
the 4506
s
eries can substitute), a
nd
• A Statement of Income from page 3 of this form.
PART 4 To establish you are age 65 or older on January 1 of the current tax year, submit one of the
following:
• Certified copy of a birth certificate,
• Florida Dirvers License or Identification Card,
• Permanent Resident Card,
• Marriage certific
ate,
• C
ertified school records,
• Certified census records, or
• Life insurance policy in effect longer than 2 years.
$ 0.00
R. 12/21
Provisional
Page 2 of 3
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 household income of all persons living in the household on
January 1 of the tax year is not more than the adjusted gross income under section 196.075, F.S.
($20,000 adjusted annually starting in 2001 by percentage change in the average cost-of-living
index.) The annual adjusted income limitation for persons 65 and older is available on the
Department’s website at floridarevenue.com/property/Pages/DataPortal.aspx.
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. I understand that under s. 196.075(5), F.S., each year I must
notify the property appraiser by May 1 if my household income exceeds the most recent income
limitation. 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.
Florida law requires property appraisers to determine whether an additional homestead exemption
may be granted. Property appraisers will notify you if additional information or documentation is
needed to determine eligibility for the additional homestead exemption requested. I grant permission
to allow the property appraiser to review the supporting documents, if requested.
I certify all information on this application, including any attachments, is true, correct, and in effect on
January 1 of the tax year.
Under penalties of perjury, I declare that I have read the foregoing Household Income Sworn
Statement and Return and the facts stated in it are true.
Signature
Print name
Date
click to sign
signature
click to edit
DR-501SC
R. 12/21
Provisional
Page 3 of 3
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., persons age 65 years or older, must live in the
home and have a household income as defined below, that does not exceed the limitation for the tax year.
The annual adjusted income limitation is available at
http://floridarevenue.com/property/documents/AdditionalHomesteadExemptions.pdf.
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.)
Examples of Supporting Documentation for the Property Appraiser
IRS Returns
Income Statements
Earning Statements
Form 1040
Form 1040-SR
Social security benefits
Pension
Interest or annuities
Rental receipts
W-2 forms
RRB-1042S
SSA-1042S
Partnership Income (1065)
Form 1099
Form 1099-A
Form 1099-MISC
RRB-1099
SSA-1099
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.
$ 0.00
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

HOUSEHOLD INCOME SWORN STATEMENT AND RETURN (Florida)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 January 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document