Form Pa 501 - Original Application For Homestead Exemption And Related Exemptions

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Tax Year 20______ Sumter County, Florida

PA 501

ORIGINAL APPLICATION FOR HOMESTEAD EXEMPTION

r.10/2013

AND RELATED EXEMPTIONS

○

New

Change

Additional

Property ID #: ______________________

Name and Mailing Address of Applicant/Co-Applicant:

Permanent Florida residency required as of January 1

Homestead exemption up to $50,000

□ $500 Widow □ $500 Widower □ $500 blind

□ $500 Totally and permanently disabled

□ Total and permanent disability-quadriplegic

□ $5000 Veteran disabled 10% or more

Legal description or physical address:

□ Service-connected totally and permanently disabled

Veteran or surviving spouse

□ Disabled Veteran confined to a wheelchair, service

connected

Applicant Social Security #:

___________________

□ Surviving spouse of veteran who died while on active duty

Co-Applicant Social Security #: ___________________

□ Surviving spouse of first responder who died in line of duty

□ Total and permanent disability-wheelchair required,

NOTE:

Disclosure of your social security number is mandatory. It is

hemiplegic, paraplegic or legally blind.

required by section 196.011 (1), Florida Statutes. The social security number

will be used to verify taxpayer identity information and homestead

(gross income required-form DR501A)

exemption information submitted to property appraisers.

□ Disabled veteran discount, 65 or older, combat related

(requires form DR-501DV)

Marital Status: ○ Single ○ Married

○ Divorced

○ Widowed ○ Separated

Did you file for exemptions in the last 2 years? Y

In addition to the above exemptions, if you are 65 or

older as of January 1st, you may apply for the limited

Where? ____________________________________

income senior exemption after January 1st. Please

___________________________________________

request form DR501SC.

Portability Applied (DR501T): Y

Proof of residence for all owners

Applicant

Co-Applicant

Other owner

Name of each owner

Date you last became a

permanent resident of Florida

Date of occupancy

Florida driver license number

Florida vehicle tag number

Florida voter registration

Immigration number (alien

card-if not a U.S. citizen)

Date of birth

Address on your last income

tax return

Phone number

I authorize this agency to obtain information to determine my eligibility for the exemptions applied for. I qualify for these exemptions under Florida Statutes. I am a

permanent resident of the State of Florida and I own and occupy the property above. I understand that under section 196.131(2), any person who knowingly gives

false information to claim homestead exemption is guilty of a misdemeanor of the first degree, punishable by imprisonment up to 1 year, a fine up to $5,000 or

both. Under penalties of perjury, I declare that I have read the forgoing application and the facts in it are true.

__________________________ _______

________________________ _______

_____________________ _______

Signature of Applicant

Date

Signature of Co-Applicant

Date

Signature of other owner Date

Please return to: Sumter County Property Appraiser, 218 E. McCollum Avenue, Bushnell, FL 33513-6124

For office use only:

Accepted by: ______________ Entered by: _____________ Enter date: ___________ Proofed by: _______________ Date: _________