INDIVIDUAL AFFIDAVIT FOR AD VALOREM TAX EXEMPTION, …
INDIVIDUAL AFFIDAVIT FOR Ad Valorem Tax Exemption
HOMES FOR THE AGED
Section 196.1975, Florida Statutes
|PART A. Completed by each resident. |
|Name |Spouse’s name |
|Tax Year 20 |
|5. |
|Earned income | |Rents | |
|Income from investments | |Dividends | |
|Social Security benefits | |Annuities | |
|Income from retirement plans | |Trusts | |
|Pensions | |Estates | |
|Interest | |Inheritances | |
|Royalties | |Direct and indirect gifts | |
|Gains from disposition of appreciated property | |Other: | |
|TOTAL GROSS INCOME | |
|PART C. Completed by each resident. |
|The above is true and correct. | |
| | | | | | | |
| Resident Date | Spouse Date |
|State of Florida, County of |State of Florida, County of |
|This statement was sworn and subscribed before me this date, by |This statement was sworn and subscribed before me this date, by |
|who is personally known to me or who has produced |who is personally known to me or who has produced |
| as type of identification. | as type of identification. |
| | | | |
|Notary Public Signature and Seal |Notary Public Signature and Seal |
-----------------------
DR-504S
R. 11/12
Rule 12D-16.002
Florida Administrative Code
Effective 11/12
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