Form Dr-570 - Application For Homestead Tax Deferral

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Application For
Dr-570
r. 07/06
Homestead Tax Deferral
This Application May Be Confidential*
Property Identification No.
I hereby make application to defer payment of a por-
tion or all of the combined total of ad valorem taxes and any
For TAx ColleCTor’s Use oNly
non-ad valorem assessments which would be covered by a
tax certificate sold under Chapter 197, Florida Statutes, for
PArT oNe
__________ .
year
Do not complete part one if entire amount is deferred.
In connection with this application, I hereby agree to submit
1) Total Taxes Due Before Discount
$
copies of my federal income tax returns for the prior year or
2) Less
Annual Adjusted
$
other documents, as may be required, for each member of
(3 or 5%)
Gross Income
the household, not including persons boarding or renting a
3) Total Deferred Taxes (1 - 2)
$
portion of the above upon which application is made.
4) Total Undeferred Taxes (1 - 3)
$
Applicant
5) Less Applicable Discount
$
Date of Birth
6) Total Due and Payable (4 - 5)
$
Property Address
Mailing Address
PArT TWo
Property Description
1) Total Deferred Taxes
$
2) Interest - Prior Year(s)
$
3) All Other Unsatisfied Liens
Including Primary Mortgage
Phone Numbers
Outstanding
$
Current value of primary mortgage outstanding on the home
4) Total (1+ 2+3)
$
$
5) Assessed Value $
And other outstanding liens on the homestead
divided by
6) %(4
5)
% (Cannot exceed 85%)
$
$
$
7) Total Primary Mortgage Outstanding
$
Annual adjusted gross income for all household members
based on Federal Income Tax Return $
divided by
8) %(7
5)
% (Cannot exceed 70%)
Annual adjusted gross income for all household members if
®
®
APPLICATION APPROVED
DISAPPROVED
no Federal Income Tax Return filed $
Signature
Date
Other Income
By
Number of Household Members
*This application is classified confidential if Federal Income Tax returns are attached.
I understand that I shall furnish proof of fire and extended
STATE OF FLORIDA
coverage insurance in the amounts which is in excess of the
County of
sum of all outstanding liens, deferred taxes, non-ad valorem as-
The following instrument was sworn to and subscribed
sessments and interest with a loss payable clause to the county
before me this date
tax collector.
(Date)
by
who is personally
I, the undersigned, hereby swear that the information on this
known to me or who has produced
application is true and correct.
as identification.
(Type of ID)
Notary Public Signature and Seal
Applicant Signature
Date
White: Tax Collector
Yellow: Applicant

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