Original Application For Homestead And Related Exemptions
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1
2ORIGINAL APPLICATION FOR HOMESTEAD
DR-501
AND RELATED TAX EXEMPTIONS
R. 12/11
Rule 12D-16.002
Permanent Florida residency required on January 1.
Florida Administrative Code
Application due to property appraiser by March 1.
New
Change
Addition
Hernando County
Tax Year 2013
Applicant
Co-applicant
Application for:
Name
HOMESTEAD EXEMPTION,
$25,000 to $50,000
*Social Security #
ADDED BENEFITS. See page 2 for qualifications and required documents.
Immigration #
By local ordinance only - senior 65 and older, limited income
$500 widowed
$500 blind
$500 disabled
Date of birth
Total and permanent disability - quadriplegic
% of ownership
Certain total and permanent disabilities - limited income and
Date of occupancy
hemiplegic, paraplegic, wheelchair required, or legally blind
Marital status
Single
Married
Divorced
Widowed
Disabled veteran discount, 65 or older
Homestead
Veteran disabled 10% or more
address
Service-connected total and permanent disability
Disabled veteran confined to wheelchair, service-connected
Parcel ID or
Other, specify:
legal description
Name and address of each owner not residing on the property
Type of deed
Date of deed
Recorded :
Book
Page
Date
Did any applicant file for exemptions last year?
Yes
No
* Disclosure of your social security number is mandatory. It is required by section 196.011(1)(b), Florida Statutes. The social security number will be
used to verify taxpayer identity and homestead exemption information submitted to property appraisers.
Proof of Residence for all Owners
Applicant
Co-applicant
Do you claim homestead in another county or state?
Yes
No
Yes
No
Previous residency outside Florida and date terminated
date
date
Florida driver license or identification card number
date
date
Evidence of relinquishing driver license from other state
Florida vehicle tag number
Florida voter registration number (if US citizen)
date
date
Declaration of domicile, enter residency date
Current employer
Address listed on your last IRS return
School location of dependent children
Bank statement and checking account mailing address
Proof of payment of utilities at homestead address
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), Florida Statutes, 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 foregoing application and the facts in it are true.
______________________________
_____________________________
_________________________
Signature, applicant
Signature, Co-applicant
Signature, property appraiser or deputy
Date
Phone
Date
Phone
Entered by
Add pages, if needed.
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