HOUSEHOLD INCOME SWORN STATEMENT AND RETURN - Senior Citizen Exemption for Persons Age 65 and Over

Sep 25, 2026

HOUSEHOLD INCOME SWORN STATEMENT AND RETURN is used by property owners age 65 and older in Florida to apply for an additional homestead exemption based on limited, adjusted gross household income. The form lists household members on January 1 and collects required prior-year income documents based on whether each member files an IRS Form 1040 series. It includes age proof requirements and a certification section confirming eligibility and mandatory income notification rules.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages3

Reading Time8 min

AccessFree to download

Application Requirements

Filing deadlines and first-time submission

Parcel and applicant information

Household Member Income Sections

PART 1 Household member list

PART 2 IRS Form 1040 series filers

PART 3 Non-1040 filers

PART 4 Proof of age

Certification and Legal Notice

Instructions and Definitions

Eligibility scope and household income definition

HOUSEHOLD INCOME SWORN STATEMENT AND RETURN Senior Citizen Exemption for Persons Age 65 and Over Section 196.075, Florida Statutes DR-501SC R. 01/22 Rule 12D-16 .002, F.A.C. Effective 01/22 Page 1 of 3 Application year 20 This form is for use by property owners as a sworn statement of adjusted gross household income to qualify for the additional homestead exemption for property owners age 65 and older, with limited income. When applying for the exemption for the first time, submit this completed statement, Original Application for Homestead and Related Tax Exemption (Form DR-501, incorporated, by reference, in Rule 12D-16 .002, Florida Administrative Code), and all required attachments with the county property appraiser on or before March 1 of the current tax year. | Parcel ID | Address | | | | | | --- | --- | --- | --- | --- | --- | | Applicant name | | | | | | | Phone | | | | | | | PART 1 List all persons living in the homestead on January 1 the year of exemption. | | | | Do not include renters or boarders | | | Name of Household Member | Date of Birth | Filed IRS return?
Yes No | | | Adjusted Gross Household Income | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Total adjusted gross household income for all household members | | | | | $ 0.00 | For each household member, submit the documents required by either PART 2 or PART 3 for last year’s income. Contact your property appraiser’s office for instructions. | PART 2 For each member who files an IRS Form 1040 series (checked “Yes” in PART 1), submit: | | | --- | --- | | • IRS 1040 series form or an Application for Automatic Extension of Time to File U.S. Individual Income Tax Return (Form 4868), if applicable, and
• Wage and Tax Statements (W-2 Forms) . | | | PART 3 For each member who does not file an IRS Form 1040 series (checked “No” in PART 1), submit: | | | • A copy of the prior year's Social Security Statement (SSA-1099), if applicable,
• An IRS Request for Transcript of Tax Return, IRS Form 4506-T. (Form 8821 or another form from the 4506 series can substitute), and
• A Statement of Income from page 3 of this form. | | | PART 4 To establish you are age 65 or older on January 1 of the current tax year, submit one of the following: | | | • Certified copy of a birth certificate,
• Florida Drivers License or Identification Card,• Permanent Resident Card,
• Marriage certificate, | • Certified school records,
• Certified census records, or
• Life insurance policy in effect longer than 2 years. | DR-501SC R. 01/22 Page 2 of 3 CERTIFICATION I certify that: • I am at least 65 years old on January 1 of the tax year I am applying for. I have attached proof of my age. • The total prior year adjusted gross household income of all persons living in the household on January 1 of the tax year is not more than the adjusted gross income under section 196.075, F.S.($20,000 adjusted annually starting in 2001 by percentage change in the average cost-of-living index. ) The annual adjusted income limitation for persons 65 and older is available on the Department’s website at [floridarevenue.com/property/Pages/DataPortal.aspx](floridarevenue.com/property/Pages/DataPortal.aspx). I qualify for this exemption under Florida law. I am a permanent resident of the State of Florida and I own and occupy the property above. I understand that under s. 196.075(5), F.S. , each year I must notify the property appraiser by May 1 if my household income exceeds the most recent income limitation. Under s. 196. 131(2), F.S. , any person who knowingly and willfully gives false information to claim homestead exemption is guilty of a misdemeanor of the first degree, punishable by a term of imprisonment up to 1 year or a fine up to $5,000 or both. Florida law requires property appraisers to determine whether an additional homestead exemption may be granted. Property appraisers

FAQs

Who should use this form to claim the additional homestead exemption?

Property owners age 65 and older applying for the additional homestead exemption with limited income use this sworn statement to report adjusted gross household income.

What documents are required for household members who file IRS Form 1040 series?

For members marked “Yes” in PART 1, submit the applicable IRS 1040 series form or Form 4868 (if applicable) and Wage and Tax Statements (W-2 forms).

How is eligibility for age 65 or older established?

To establish age 65+ on January 1 of the tax year, submit one of the listed proofs such as a certified birth certificate, Florida driver license/ID, permanent resident card, or other acceptable records.

Sep 25, 2026

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