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DR 501SC

Part E:

R. 02/08

Worksheet for persons who have not filed IRS Form 1040.

NOTE: If a person’s income is below the filing thresholds for the IRS and the person does not file an income tax return,

list the person’s gross income in this part. If a person intends to take deductions from gross income, file Form 1040 and

complete part C; enter adjusted gross income in part A. Complete additional Part E of form for each person who does not

file income tax return.

Earned Income

Veterans Administration Benefits

Investment Income

Income from Retirement Plans

Capital Gains or (losses)

Income from Pensions

Interest Income

Income from Trust Funds

Rents

Other (specify)

Royalties

Dividends

Annuities

Social Security Benefits*

Total Income for this Household Member Who does not File a Federal Income Tax Return

Instructions:

In order to qualify for an additional homestead exemption of up $50,000 for persons age 65 years or older, the “Household

Income” (cumulative “adjusted gross income”) of all persons living in the home cannot exceed the maximum household

adjusted gross income. (See definition (b) below or reverse side.) This exemption applies only to the property taxes levied

by the taxing authority granting the exemption.

Definitions: Section 196.075, Florida Statutes. Additional homestead exemption for persons

65 and older. -- As used on this application, the terms:

(a) “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.

(b) “Household income” means the adjusted gross income, as defined in s. 62 of the

United States 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 includes, rental receipts, pension statements, annuity statements, income statements,

interest statements, and any Wage and Earnings Statements; Form W series forms, Form 1099 series forms, Form 1042 series

forms, Form 1065 series forms, Social Security Benefits Worksheets, etc., and/or Form 4506, or any other documentation

supporting the applicant’s household income.) NOTE: Income documentation of all persons living in the household

should be submitted before May 1 for prompt consideration. No documentation can be accepted after June 1.

Supporting documentation will be destroyed upon determination of eligibility unless the applicant requests return

of the documentation.

According to the I.R.S., a person cannot file Form 1040EZ if he/she has taxable social security benefits, and the person must

file either Form 1040 or Form 1040A. *If you have social security benefits, according to I.R.S. they are not automatically

included in adjusted gross income. If your gross income is below the filing thresholds for federal income tax, consult I.R.S.

to verify that no portion of Social Security income is included in adjusted gross income to meet the current Florida limit on

adjusted gross income as factored for cost of living.

If your combined benefits and other income exceed other applicable thresholds, some portions of your Social Security income

may be taxable. Consult I.R.S. for portions of Social Security income that may be taxable based on current formulas.

NOTE: According to the I.R.S., social security benefits include monthly survivor and disability benefits. They do not include

supplemental security (SSI) payments, which are not taxable.

NOTE: 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. Disclosure of your social security number is

mandatory for the regular homestead exemption. It is required by section 196.011(1), Florida Statutes. If you have not

already provided your social security number to the property appraiser it should be provided now. The social security

number will be used to verify taxpayer identity information and homestead exemption information submitted to property

appraisers.

Form Dr 501sc - Sworn Statement Of Adjusted Gross Income Of Household And Return - 2008 Page 2

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