Local Business Tax Account Application For Exemption - Lee County
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1LOCAL BUSINESS TAX ACCOUNT
APPLICATION FOR EXEMPTION
Name: ______________________________________________ Age:______ DOB:
_____________
( Last)
(First)
(Middle Initial)
Home address:____________________________________________________________________
Home Phone
__________________________________________________
: (
) __________________
Business Name:
______________________________________________
(if other than applicant's)_________
Business Address
:_______________________________________________________________________
Business Phone:
_____________________________________________
(______)____________________
Do you reside in Lee County?
Yes _____ No ______
Driver's License Number or Florida ID Card Number: ______________________________
Reason For Exemption: (Only check applicable box below)
_____
I, the undersigned, am 65 years of age or older, with not more than one employee or helper,
and will use my own capital not in excess of $1,000. (Copy of Drivers License or Florida
ID Card as proof of age.)
_____
I, the undersigned, am a disabled person incapable of manual labor, with not more than
one employee or helper, and will use my own capital not in excess of $1,000. (Certificate or
statement from a reputable physician as to the nature and extent of the disability.)
Note: Certificate or statement must indicate the physician’s license number.
_____
I, the undersigned, am a widow with minor dependents, with not more than one employee
or helper, and will use my own capital not in excess of $1,000.. (A copy of the Death
Certificate and the applicant’s identification are required)
UNDER PENALTIES OF PERJURY, I HEREBY DECLARE THE STATEMENTS ABOVE ARE
TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Signature of applicant: _____________________________________________
Date:______________________
Note: Fraudulent information on this application may result in revocation of exempt status per Florida Statute.
(Florida Statute 205.162) Allows disabled persons, the aged and widows with minor dependents to
engage in any business or occupation in counties in which they live without being required to pay for
a business tax receipt.
AgeExemptAppl
Form#097
Rev.12/07/09
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