LCPA 501SC R10/13
LAKE COUNTY LIMITED INCOME SENIOR APPLICATION/RETURN
SWORN STATEMENT OF HOUSEHOLD ADJUSTED GROSS INCOME
For Persons Age 65 and Over per Section 196.075, Florida Statutes
FILING DEADLINE MARCH 1
1 TAX YEAR: _______________ ALTERNATE KEY #: _____________________________
2 OWNERS NAMES: _______________________________________________________________________________________________
3 ADDRESS WHERE YOU LIVE: _____________________________________________________________________________________
4 MAILING ADDRESS IF DIFFERENT FROM ADDRESS WHERE YOU LIVE: ______________________________________________
CITY: ___________________________________________________ STATE__________________ ZIP CODE __________________
5
List all persons living in the homestead as of January 1 of the tax year
List Name of Each
Household Member
Date of
Birth
Do you file an IRS return?
Yes No
Year you
Moved
Here?
Adjusted Gross
Income
*Leave blank if return or income
is not yet received
• If you answered Yes above, you must submit your prior year IRS return and wage and tax statements by May 1 to
expedite processing.
• If you answered No above, you must submit copies of all 1099, W-2’s and all other sources of income from the prior
year by May 1 to expedite processing along with the statement of income worksheet below for each owner.
• Income and household members are defined under Section 196.075 of Florida Statutes.
6
Statement of Income * ONLY NEEDED IF YOU DO NOT FILE AN IRS RETURN
Name:
Earned Income Social Security benefits
Investment Income V A benefits
Capital gains/losses Income from retirement plans
Interest Income Income from pensions
Rents Income from trust funds
Royalties Dividends
Annuities Other (specify)
Total Income for this household member
$
Note: Use additional forms other household members “statement of income” if needed.
I authorize the Property Appraiser’s Office to obtain information from utility companies and other sources necessary to determine my eligibility for the exemption
applied for. Furthermore, I certify that I am at least 65 years old on January 1 for the tax year I am applying for and 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 as defined in section 62 of the US Internal Revenue Code. I also
certify that I am a permanent resident of the State of Florida and I own and occupy the above property as my permanent residence. Under FS 196.131(2), any person
who knowingly and willfully gives false information for the purpose of claiming homestead exemption is guilty of a misdemeanor of the first degree, punishable by a
term of imprisonment not exceeding 1 year or a fine not exceeding $5,000 or both. Further, under penalties of perjury, I declare that I have read the foregoing
application and Statement of Adjusted Gross Income and the facts in it are true and correct. Disclosure of your email address is not required. By providing an email
address you grant explicit consent for the Property Appraiser to further communicate with you via email regarding this exemption or other products or services. Email
addresses are considered public record under Florida Law and are not exempt from public-records requirements.
7 8
_____________________________________ ____________________________________________ ________________________________
Signature/Owner Signature/Co-owner Date
9 10
______________________________ ____________________________________ __________________________
Email Address Phone number Office use only
