Form Dr 501Sc – Fill Out and Use This PDF

		DR-501SC
	HOUSEHOLD INCOME	R. 12/21
		Rule 12D-16.002, F.A.C.
	SWORN STATEMENT AND RETURN	Provisional
		Page 1 of 3
	Senior 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

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, and

•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,

•An IRS Request for Transcript of Tax Return, IRS Form 4506-T. (Form 8821 or another form from the 4506 series can substitute), and

•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:

DR-501SC

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.

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		Social security benefits	W-2 forms	Form 1099
Form 1040-SR		Pension	RRB-1042S	Form 1099-A
		Interest or annuities	SSA-1042S	Form 1099-MISC
		Rental receipts	Partnership Income (1065)	RRB-1099
				SSA-1099

Supporting documentation will be destroyed after use, unless you ask the property appraiser to return the documents.

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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.