Fillable Form Pc501sc Application For Senior Citizen Exemption printable pdf download

PC501SC

APPLICATION FOR SENIOR CITIZEN EXEMPTION

Rev 10/11

Sworn Statement of Adjusted Gross Income of Household and Return

Clear Form

APPLICATION DEADLINE MARCH 1

PART 1

(Section 196.075 (4)(d), Florida Statutes)

___________

APPLICATION YEAR

___________

DISTRICT

__________________________

PARCEL NUMBER

Disclosure of your Social Security number is not mandatory in

order to receive this exemption if it was provided to the Property

Appraiser to receive the regular homestead exemption. DIS-

Applicant Name

CLOSURE OF YOUR SOCIAL SECURITY NUMBER IS MAN-

DATORY FOR THE REGULAR HOMESTEAD EXEMPTION. It

Applicant or Household Member

is required by section 196.01 1(1), Florida Statutes. If you have

not already provided your social security number to the Property

Address

Appraiser it should be provided now . The social security num-

ber will be used to verify taxpayer identity information and home-

Address

stead exemption information submitted to property appraisers.

Address

APPLICANT

Additional Household Member 1

Additional Household Member 2

Name

Date of Birth

Social Security

Number

Does Applicant File a Federal

Income Tax Return?

YES

If NO, please submit

Income Worksheet (Part 2)

TOTAL ADJUSTED GROSS INCOME FOR ALL HOUSEHOLD MEMBERS $_____________________

If income information is not available by March 1, send application anyway. You have until JUNE 1 to send income info

AFFIRMATION

I hereby authorize the County Property Appraiser’s off ce to obtain information from utility companies and other sources necessary to

determine my continuing eligibility for the exemption. I must contact the County Property Appraiser to obtain the maximum Household

adjusted gross income amount. This amount is subject to change each year. I hereby make application for the exemption indicated

and aff rm that I do qualify for same under Florida Statutes. I am a permanent resident of the State of Florida and I own and occupy the

property described above. I understand that section 196.131(2), Florida Statutes provides that any person who knowingly and willfully

gives false information for the purpose of claiming homestead exemption is guilty of a misdemeanor of the f rst degree, punishable by

a term of imprisonment not exceeding 1 year, or a f ne not exceeding $5000 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. I hereby certify

that I am at least 65 years of age as of

January 1 of the current year

and that the total prior year adjusted gross income for all

persons living in the household on

January 1 of the current year,

does not exceed the adjusted gross income as deﬁ ned in

s.62 of the United States Internal Revenue Code.

Date

Applicant Signature

_________________________________

________________________________

Phone Number (

)_____________________

Deputy ________________________

(Property Appraiser Representative)

OFFICE US E ONLY

Income Verified:

Proof of Age:

Other ____________

1040/A

B/ C

Docs

Med Card

Initials ___________

D/L

Form Pc501sc Application For Senior Citizen Exemption

Related Articles

Related forms

Related Categories