Form Dr-504ha - Ad Valorem Tax Exemption Application And Return Homes For The Aged
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2AD VALOREM TAX EXEMPTION APPLICATION AND RETURN
DR-504HA
N. 11/01
HOMES FOR THE AGED
Section 196.1975, Florida Statutes
This form must be signed and returned on or before March 1.
For use by nonprofit homes for the aged for exemption
Organization
Facility name
Mailing
Facility address,
address
if different
Phone
Phone
Legal description or parcel ID
1. Is the applicant a corporation pursuant to Chapter 617, F.S.?
yes
no
If yes, please provide a copy of its designation letter from the Secretary of State.
If yes, is the corporation exempt from federal income tax under 501(c)(3), Internal Revenue Code?
yes
no
If yes, provide a copy of the current exemption determination letter from the Internal Revenue Service.
Is the applicant a Florida limited partnership, of which the sole general partner is a corporation
yes
no
pursuant to Chapter 617, F.S. and exempt from federal income tax under 501(c )(3), I.R.C.?
If yes, provide a copy of the current exemption determination letter from the Internal Revenue Service,
and a copy of its acknowledgement letter from the Secretary of State.
If the applicant is neither of the above, what form is the organization?
2. Do you provide any of the following:
no Assisted living facility (Chapter 439, F.S.)?
Medical facilities?
yes
no Nursing services?
yes
yes
no
If yes, did you have a valid license granted by the Agency for Healthcare Administration on January 1
yes
no
of this year?
3. Owner’s statement of full value:
Real property
Real property improvement
Tangible personal property
4. Is any of this property rented or leased to other than residents?
yes
no
If yes, attach a copy of all active rental and/or lease contracts last year.
5. Portion of property used exclusively to conduct religious services and nursing or medical services
%
6. Is any portion of the above property used for non-exempt purposes? If yes, attach a detailed
yes
no
explanation.
7. Number of units and apartments in home, excluding units accounted for in number 4 above
8. Number of units and apartments that qualify for exempt status under s.196.1975(4), F.S. See instructions.
9. Percent of the units and apartments that are exempt (8 divided by 7)
%
This same percentage applies to common areas, which qualify for an exemption as provided under s. 196.1975(12) unless 25% or more of
the units or apartments are exempt which would result in a total exemption for common areas as provided for in s. 196.1975 (8)
10. Number of units or apartments qualifying for the $25,000 exemption under s. 196.1975(9)(a), F.S.,
other than those units exempt under s. 196.1975(3) and (4), F.S.
I understand that the property appraiser may require supplemental and additional information, other than the application,
and I am willing to comply with any reasonable request to furnish this information, related to requirements in s. 196.1975, F.S.
Under penalties of perjury, I declare that I have read this application and all information on this form and any attachments
is true and correct.
Signature
Title
Date
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