Form Dr-501a - Statement Of Gross Income
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1DR-501A
R. 11/12
STATEMENT OF GROSS INCOME
Rule 12D-16.002
Florida Administrative Code
Effective 11/12
Section 196.101(4)(c), Florida Statutes
Date
Applicants for the Exemption for Totally and Permanently Disabled Persons, Section 196.101, F.S., must
complete, sign, and attach this statement to the exemption application, Form DR-501.
Applicant
Address of
name
homestead
Parcel ID
Name of all other persons living at the homestead
1.
5.
2.
6.
3.
7.
4.
8.
Gross Income: Include the incomes of all persons above. Attach last year's Federal Income Tax Returns and
Wage and Income Statements (W-2) for all persons above.
HOUSEHOLD GROSS INCOME FOR THE YEAR 20
Earned income
Social security benefits
Income from investments
Veterans Administration benefits
Income from retirement plans
Gains from disposition of
appreciated property
Pensions
Interest
Trusts
Rents
Estates
Royalties
Inheritances
Dividends
Direct and indirect gifts
Annuities
Other, specify:
TOTAL GROSS INCOME
I certify this Statement of Gross Income is true and correct to the best of my knowledge.
State of Florida
Signature, applicant
County of
This instrument was sworn to and subscribed before me this date,
, by
Date
who is personally known to me or who has produced
as identification.
Type of ID
Notary public, signature and seal
Add pages, if needed.
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Parent category: Financial