Original Application For Ad Valorem Tax Exemption Form - Lake County, Fl
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1
2FILING DEADLINE MARCH 1
LCPA 501 R.09/09
ORIGINAL APPLICATION FOR AD VALOREM TAX EXEMPTION
LAKE COUNTY, FL
New ______
Change ______
Additional ______
TAX YEAR: _________________
ALTERNATE KEY #: ___________________________PARCEL ID #__________________________________________________________
MAILING ADDRESS: _________________________________________________________________________________________________
CITY: _____________________________________________STATE__________________ZIP + 4 _____________________
PHYSICAL ADDRESS: _________________________________________________________________________________________________
PERMANENT FLORIDA RESIDENCY REQUIRED AS OF JANUARY 1
PLEASE MARK EXEMPTIONS FOR WHICH YOU ARE APPLYING (Documentation Required)
Homestead
$500 Widow’s / Widower’s
$500 Blind
$500 Disability
$5,000 Veteran’s Disability
Total & Permanent Disability -
Total & Permanent Disability -
Service-Connected Total
ty
Quadriplegic
Civilian
& Permanent Disabili
*If you wish to apply for an additional homestead exemption enacted by local ordinance for persons age 65 and older you must file form DR501SC.
However, you must either receive, or apply for, the regular homestead to get the 65 and older additional homestead exemption. If you have already
received regular homestead exemption, you do not need to file another form LCPA 501.
NOTE: Disclosure of your social security number is mandatory. It is required by section 196.011(1), Florida Statutes. The social security number
will be used to verify taxpayer identity information and homestead exemption information submitted to property appraisers.
Owner
Owner
Owner
Applicant Name
Are you or your spouse currently
Yes
No
Yes
No
Yes
No
receiving any permanent-residency based
tax benefits on ANY other property? (i.e.
homestead, school tax relief, tax rebate or
credit, rollback, etc. )
If yes, where?
Did you have Homestead last year?
Yes
No
Yes
No
Yes
No
If yes, what county and state?
If no, your last year’s address
Date you last became a permanent
resident of Florida
Date of occupancy
Do you or your spouse have an out of
Yes
No
Yes
No
Yes
No
state drivers license or vehicle?
If yes, where?
Florida drivers license number
and date license issued
Florida vehicle tag number
Florida voter registration number
(if U.S. citizen)
Immigration number (non-U.S.
citizen attach copy of alien card)
Date of birth
MM/DD/YYYY
Social Security number
Marital Status
Single
Married
Widow
Single
Married
Widow
Single
Married
Widow
Widower
Divorced
Widower
Divorced
Widower
Divorced
Affidavit of Florida Resident (residency
DATE
ORB/PAGE
DATE
ORB/PAGE
DATE
ORB/PAGE
date & ORB/PAGE)
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
st
information is not received by March 1
, your application will be processed for whatever exemptions you qualify for on 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.
______________________________
_____________________________
____________________________
Signature
Signature
Signature
___________________
_______________________
________________
_________________
Date
Phone number
Deputy
Deputy
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