Original Application Form For Ad Valorem Tax Exemption - Florida Department Of Revenue

Florida Department of Revenue

Original Application for Ad Valorem Tax Exemption

Tax Year_____________________

New________ Change________ Additional________

Property identification number: ____________________________

Applicant/Co-applicant Name and Address:

_____________________________________________

Permanent Florida residency required

_____________________________________________

as of January 1

_____________________________________________

$25,000 Homestead exemption*(see additional information)

□

$500 Widow’s exemption

□

_____________________________________________

$500 Widower’s exemption

□

_____________________________________________

$500 Disability exemption

□

Legal Description:

$500 Blind persons exemption

□

Total and permanent disability exemption-Quadriplegics

□

_____________________________________________

(Documentation required)

_____________________________________________

Service connected total and permanent disability exemption

□

_____________________________________________

(Documentation required)

_____________________________________________

Exemption for disabled veterans confined to wheelchairs

□

(Documentation required)

_____________________________________________

Total and permanent disability exemption

□

.: ____________________

Applicant Social Security No

(Documentation required)

*If you wish to apply for an additional homestead exemption enacted by

__________________

Co-Applicant Social Security No:

local ordinance for persons age 65 and older you must file form DR-

501SC. However, you must either receive, or apply for, the regular

homestead to get the 65 and older additional homestead exemption. If you

NOTE: Disclosure of your social security number is mandatory. It is required by section

196.011 (1), Florida Statures. The social security number will be used to verify

have already received regular homestead exemption, you do not need to

taxpayer identity information, homestead exemption information submitted to property

file another form DR-501.

appraisers, and intangible tax information submitted to the Department of Revenue

.

Marital status:

□ Single

□ Married

Ownership information

□ Widow

□ Divorced

□ Widower

Did you file tax exemptions last year? □ Yes

□ No

Percent of ownership________ Type of deed ________________

Where: _______________________________________________

Recorded: Book ___________ Page _______________________

If no, your last year’s address

Date recorded______________ Date of deed__________________

______________________________________________________

Proof of residences for all owners

Owners

Spouse

Other owner

Give address of each owner not

residing on property

Date you last became a permanent

Resident of Florida

Date of occupancy

Florida driver license number

(Date)

(Date)

(Date)

Florida vehicle tag number

Florida voter registration number

(Date)

(Date)

(Date)

(if U.S. citizen)

Immigration number

(Date)

(Date)

(Date)

(Alien Card-if not a U.S. citizen)

Declaration of domicile

Res. date

Res. date

Res. date

Date of birth

Current employer

Address listed on your last IRS return

I hereby authorize this agency to obtain information necessary to determine my eligibility for the exemption(s) applied for. NOTE: If all information is not received

st

by March 1

, your application will be processed for whatever exemption you qualify for at that date.

I hereby make application for the exemptions indicated and affirm that I do qualify for same under Florida Statutes. I am a permanent resident of the State of Florida

and I own and occupy the property described above. I understand that section 196.131(2) Florida Statutes, provides that any person who knowingly and willfully gives false

information for the purpose of claiming homestead exemption is guilty of a misdemeanor of the first degree, punishable by a term of imprisonment not exceeding 1 year or a fine

not exceeding $5,000 or both. Further, under penalties of perjury, I declare that I have read the foregoing application and the facts in it are true.

_____________________________________

_____________________________________

For Official Use Only

Signature of co-applicant

Signature of co-applicant

_____________________________________

Signature of deputy

_____________________________________

_____________________________________

__________________________________________

Date

Phone number

Entered by