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Signature of Spouse

451 West Third Street

Dayton, OH 45422-1021

(937) 225-4341

www.mcauditor.org

Homestead Exemption Application for Senior Citizens, Disabled Persons and Surviving Spouses

Real Property & Manufactured or mobile homes: File with the county auditor on or before Dec. 31

Please read ALL the instructions before applying for Homestead.

Disabled applicants must complete the Certificate of Disability on the back of this form or attach a separate certification

of disability from an eligible state/federal agency. See Instructions for filing a Late Application.

Current application Late application for prior year

Application of person who received homestead for 2013 or for 2014 manufactured or mobile homes (Form

DTE105G must accompany this application, see attached)

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

current law (Form DTE105G must accompany this application, see attached)

Type of application: Senior citizen (age 65 and older) Disabled person Surviving spouse

Type of home: Single family dwelling Unit in a multi-unit dwelling Land under a manufactured or mobile home

Condominium Manufactured or mobile home Unit in a housing cooperative

In order to be eligible for the homestead exemption, the form of ownership must be identified. 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 qualified housing cooperative. See DTE105A/Supplement for additional information

If either the applicant or spouse own any other homes, please provide the address(es) and county(ies) (Attach separate sheet if more

than one additional home is o

wned.)

Address City State Zip County

1) Total income for the year preceding

year of application, if known (see instructions): $___________________

2) Have you or do you intend to file an Ohio income tax return for last year? □ Yes □ No

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 financial 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 defined in I.R.C. 6103 and received from the Internal Revenue Service. I expressly waive the confidentiality 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 confidentiality of the information received and the

information shall not otherwise be re-disclosed.

Signature of Applicant

Mailing Address Date

Phone Number E-mail Address

Applicant’s Name:_____________________________________ Date of Birth:___________ SSN:________________

Name of Spouse:______________________________________ Date of Birth:___________ SSN:________________

Address of Home: _________________________________________________________________________________

County in which Home is located: ___________________ Parcel Number or Registration # ____________________

(from tax bill or county auditor)

DTE 105A

Rev. 01/21

For Auditors Use Only

Year of eligibility: ______

LATE APPLICATION: 2019 OHIO MODIFIED ADJUSTED GROSS INCOM

E CANNOT EXCEED $33,600 FOR APPLICANT AND SPOUSE

CURRENT APPLICATION: 2020 OHIO MODIFIED ADJUSTED GROSS INCOME CANNOT EXCEED $34,200 FOR APPLICANT AND SPOUSE

(If No, Provide a copy of your Federal

Return or complete form DTE105H)

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

and is now permanently and totally disabled according to the above de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 defined above. See the next page of this form for

more information on what constitutes acceptable proof of permanent disability.

DTE 105E

Rev. 10/19

Certificate of Disability for the Homestead Exemption

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

January of the year of application for reduction in real estate taxes, some impairment in body or mind that makes

the person unable to work at any substantially remunerative employment that the person is reasonably able to perform

and that will, with reasonable probability, continue for an indefinite period of at least twelve months without any

present indication of recovery therefrom or has been certified 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.

Name of applicant

Date

________ _

FOR COUNTY AUDITOR'S USE ONLY:

Taxing district and parcel or registration number:

Auditor's application number:

First year for homestead exemption:

Date filed:

Name on tax duplicate:

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

Method of Verification (must complete one):

Tax commissioner portal: Year: Total MAGI: No information returned

Ohio tax return (line 3 plus 11 of Ohio Schedule A): Year Total MAGI:

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

(line 21, 1040A): Year Total MAGI:

(line 37, 1040): Year Total MAGI:

Worksheet (attached): Estimated MAGI

Granted Denied

County auditor (or representative) Date

Acceptable and Unacceptable Proofs of Permanent and Total Disability

Physician’s Certicate: Acceptable. An application based

on physical disability must include a certicate signed by a

physician. An application based on mental disability must

include a certicate signed by a physician or a psychologist

licensed to practice in Ohio. Note: Neither a chiropractor

nor certified nurse practitioner is considered a “physician”

for purposes of the Homestead Law. (Form DTE 105E)

Federal Agencies:

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

form indicating that an applicant is “disabled” is

acceptable. The SSA only gives disability benefits to

those who are permanently and totally disabled. (The

documentation provided must show disability/eligibility

date.)

Department of Veterans Affairs (VA): Veterans with a

total service-connected disability or veterans who

are receiving 100% compensation for service-

connected disabilities following a determination of

individual unemployability should file 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 definition found in R.C.

323.151(D) (provided on form DTE 105A), the veteran

must have a doctor or qualifying psychologist complete

this form. No VA documentation reflects the statutory

definition 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-specific and do not

rule out the possibility of other substantially remunerative

employment using a different set of skills.

DTE 105G - 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).

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 qualification 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 ________________________________________________________________

axing 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

DTE105G

Rev. 11/13

DTE 105A

Rev. 10/19

Please read before you complete the application.

What is the Homestead Exemption? The homestead exemp-

tionprovides a reduction in propertytaxes to quali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 this form, you affirm

under penalty of perjury that your statements on theform are

true, accurate and complete to the best of your knowledge and

belief and that you are authorizing the tax commissioner andthe

county auditor to review financial and tax information filed 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.

Qualifications 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firstfile,orbedeterminedtohavebeen

permanentlyandtotally disabled (see definition atright),orbea

surviving spouse(seedefinition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filetheapplication.Formanufactured

ormobilehomeowners,thedatesapplytotheyearfollowingthe

year in which you file 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 mortgagor 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. (3) If you are

applying for homestead and did not qualify for the exemption

for 2013 (2014 for manufactured homes), your total income

cannot exceed the amount set by law.

Beginning tax year 2020 for real property and tax year 2021 for

manufactured homes, “total income” is defined as “modified

adjusted gross income,” which is comprised of Ohio

adjusted gross income plus any business income

deducted on Schedule A, line 11 of your Ohio IT 1040.

“Total Income” is that of the owner and the owner’s spouse for

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

do not file 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 file a federalincome tax return, you will be asked

to produce evidence of income and deductions allowable

under Ohio law so that theauditormayestimateOhiomodified

adjustedgrossincome.

Current Application: If you qualify for the homestead exemption

forthefirsttimethisyear(forrealproperty)orforthefirst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qualified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filingacur-

rent application, but you did not file a current application for that

year, you may file a late application for the missed year

by checking the late application box on the front of this form. You

mayonlyfilealateapplicationforthesamepropertyforwhichyou

arefilingacurrentapplication.

Definition 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firstdayofJanuaryoftheyearforwhich

the homestead exemption is requested, some impairment of body

or mind that makes him/her unfit to work at any

substantially remunerative employment which he/she is

reasonably able to perform and which will, with reasonable

probability, continue for an indenite period of at least 12

months without any present indication of recovery, or who has

been certified as totally andpermanentlydisabled by an eligible

state or federal agency.

Change in Residency

Persons who received a homestead exemption on any property within the state for tax year 2013 may move to a new residence

within the state and qualify for the homestead exemption on a new, otherwise qualifying home without meeting the income

threshold test imposed upon new applicants. The homeowner must present sufficient evidence to the auditor so that the

auditor can verify the existence of a homestead exemption for tax year 2013. DTE Form 105G has been created for this

purpose.

DTE 105H

Rev. 10/19

Addendum to the Homestead Exemption Application for

Senior Citizens, Disabled Persons and Surviving Spouses

In order to qualify an applicant for the homestead reduction, your county auditor is required to verify an applicant’s modied adjusted

gross income for the year prior to the year of application. Generally, the auditor is able to verify the modied adjusted gross income of the

applicant and the applicant’s spouse through use of the portal designed specically for the county auditor or by a review of the tax return(s)

of the applicant and the applicant’s spouse for the year prior to the year of application.

You have received this form because the auditor has been unable to verify your income through a review of the portal or tax returns.

So that the auditor may verify income, please complete the worksheet below. If you are married, the amounts must include income and

deductions for both you and your spouse. The auditor will use the result for purposes of qualifying you for the Homestead Exemption. The

estimate of income derived is not an indication of whether or not you or your spouse were required to le income tax returns.

Applicant’s name

Home address

County Tax Year

Estimated Ohio Modied Gross Income Calculator for Homestead Deduction Only

Income Amount

1. W-2 and W-2G income ........................................................................................................................................ $

2. 1099-R income from retirement plans ................................................................................................................. $

3. 1099-DIV and 1099-INT income .........................................................................................................................$

4. Other income (1099-MISC, etc.; do not include Social Security benets) .......................................................... $

5. Business income (including any farm or rental income, or any income that would be included on

Federal Schedules C, E and F). If ling an Ohio tax return, include any business income deducted

on line 11 of Schedule A ...................................................................................................................................... $

6. Total income (add lines 1-4) ............................................................................................................................... $

Deductions

7. Uniformed services retirement income, Military Injury Relief Fund amounts or military pay for Ohio

residents received while the military member was stationed outside Ohio ......................................................... $

8. Disability and survivorship benets (do not include pension continuation benets) ........................................... $

9. Unreimbursed long-term care insurance premiums, unsubsidized health care insurance premiums,

excess health care expenses, funds deposited into a medical savings account and qualied

organ donor expenses ........................................................................................................................................ $

10. Ohio STABLE and 529 contributions ................................................................................................................. $

11.Total deductions (add lines 7-10) ........................................................................................................................ $

12. Estimated Ohio modied gross income (subtract line 11 from line 6) ................................................................ $

I declare under penalty of perjury that my (our) income for the prior year is reected in the information provided above.

Applicant Date

Spouse Date

Note: If married, amounts on each line must include total income

and deductions from both you and your spouse.

Income

Line 1: Enter amounts from box 1 of your Form(s) W-2. Also enter

gambling winnings reported in box 1 of your Form(s) W-2G.

Line 2: Enter your retirement income reported in box 2a of your

Form(s) 1099-R. The amount in this box is the taxable amount.

Line 3: Enter your taxable interest income reported in box 1 of your

Form(s) 1099-INT. Also enter your ordinary dividends reported

in box 1a of your Form(s) 1099-DIV. Both of these amounts are

taxable.

Line 4: Enter income from any other sources not included above

(income reported on Form(s) 1099-MISC, self-employment

income, business income). Do NOT include any Social Security

benets as they are not taxable in Ohio.

Line 5: If you have led an Ohio Tax Return, enter previously

deducted business income as reported on line 11 of Ohio Schedule

A (from line 11 of Ohio IT BUS). If you did not le an Ohio tax

return, enter any business income you received, including income

that was reported or could be reported on Federal Schedules C,

E and F.

Deductions

Line 7: Enter any military retirement income if both of the

following are true: 1) The income is included in federal adjusted

gross income; and 2) The income is related to your service in the

uniformed services or reserve components thereof, or the National

Guard. The term “uniformed services” includes the Army, Navy, Air

Force, Marine Corps, Coast Guard, the commissioned corps of the

National Oceanic and Atmospheric Administration, and the Public

Health Service. If you led an Ohio tax return, enter the amount

from lines 26-30 of Ohio Schedule A.

Line 8: Enter disability and survivor’s benets to the extent

included in federal adjusted gross income or that you included

on line 2. To determine if amounts are disability or survivor’s

benets, you should refer to the terms of the plan under which

the benets are paid. You may not deduct: 1) Temporary wage

continuation payments; 2) Retirement benets that converted from

disability benets upon reaching a minimum retirement age; OR

3) Payments for temporary illnesses or injuries (such as sick pay

provided by an employer or third party). Additionally, any amounts

payable without the death of a covered individual as a precondition

are not survivor’s benets. If you led an Ohio tax return, enter the

amount from lines 33-36 of Ohio Schedule A.

Line 9: Enter your unreimbursed long-term care insurance

premiums and unsubsidized health care insurance premiums.

Unreimbursed long-term care insurance premiums are those that

you pay during the calendar year on your own; a company, etc. is

not paying you back. Medicare Part B is not a deduction because

Social Security is not included as taxable income. Unsubsidized

health care insurance premiums are those that are not partially

paid by someone else such as an employer or a retirement plan.

Also include on this line any out-of-pocket medical expenses you

paid during the tax year and were not reimbursed to you. Some

examples of qualifying expenses include costs for prescription

medicine and insulin; hospital costs and nursing care; copayments

for medical care; eyeglasses, hearing aids, braces, crutches and

wheelchairs.

Line 10: Enter any contributions you made to an Ohio 529

(CollegeAdvantage) savings plan or any STABLE (Ohio ABLE)

account.

DTE 105H

Rev. 10/19

Please read this before you complete the front of this application.

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