DTE 105A Rev. 9/16 Homestead Exemption Application for Senior Citizens, Disabled Persons and Surviving Spouses Real property: File with the county auditor on or before Dec. 31. Manufactured or mobile homes: File with the county auditor on or before the first Monday in June. Please read the instructions on the back of this form before you complete it. Disabled applicants must complete form DTE 105E, Certificate of Disability for the Homestead Exemption, and attach it or a separate certification of disability status from an eligible state or federal agency to this application. See Late Application in the instructions on page 3 of this form. Current application Late application for prior year Application of person who received homestead reduction for 2013 or for 2014 for manufactured or mobile homes. Form DTE 105G must accompany this application. Application of person who received the homestead reduction for 2006 that is greater than the reduction calculated under the current law. Form DTE 105G must accompany this application. Type of application: Senior citizen (must be at least age 65 by Dec. 31st of the year for which the exemption is sought) Disabled person (must be permanently and totally disabled on Jan. 1 of the year for which exemption is sought) Surviving spouse (must have been at least 59 years old on the date of the spouse's death and must meet all other homestead exemption requirements) Type of home: Single family dwelling Unit in a multi-unit dwelling Condominium Unit in a housing cooperative Manufactured or mobile home Applicant's name Name of spouse Home address County in which home is located Land under a manufactured or mobile home Applicant's date of birth Spouse's date of birth SSN SSN Taxing district and parcel or registration number from tax bill or available from county auditor FOR COUNTY AUDITOR'S USE ONLY: Taxing district and parcel or registration number First year for homestead exemption Date filed Name on tax duplicate Taxable value of homestead: Taxable land Taxable bldg. Method of Verification (must complete one): Tax commissioner portal: Year Ohio tax return (line 3): Year Federal tax return (line 4, 1040EZ): Year (line 21, 1040A): Year (line 37, 1040): Year Worksheet (attached): Estimated OAGI Granted Denied Date -1American LegalNet, Inc. www.FormsWorkFlow.com Auditor's application number Taxable total Total OAGI Total OAGI Total FAGI Total FAGI Total FAGI No information returned County auditor (or representative) DTE 105A Rev. 9/16 In order to be eligible for the homestead exemption, the form of ownership must be identified. Property that is owned by a corporation, partnership, limited liability company or other legal entity does not qualify for the exemption. Check the box that applies to this property. The applicant is: an individual named on the deed a purchaser under a land installment contract a life tenant under a life estate a mortgagor (borrower) for an outstanding mortgage trustee of a trust with the right to live in the property the settlor, under a revocable or irrevocable inter vivos trust, holding title to a homestead occupied by the settlor as a right under the trust a stockholder in a qualified housing cooperative. See form DTE 105A ­ Supplement for additional information. other If the applicant or the applicant's spouse owns a second or vacation home, please provide the address and county below. Address City Yes State No ZIP code County Have you or do you intend to file an Ohio income tax return for last year? Total income for the year preceding year of application, if known (see instructions): I declare under penalty of perjury that (1) I occupied this property as my principal place of residence on Jan. 1 of the year(s) for which I am requesting the homestead exemption, (2) I currently occupy this property as my principal place of residence, (3) I did not acquire this homestead from a relative or in-law, other than my spouse, for the purpose of qualifying for the homestead exemption, (4) my total income for myself and my spouse for the preceding year is as indicated above and (5) I have examined this application, and to the best of my knowledge and belief, this application is true, correct and complete. I (we) acknowledge that by signing this application, I (we) delegate to both the Ohio tax commissioner and to the auditor of the county in which the property for which I am seeking exemption is located, and to their designated agents, the authority to release my tax and/or financial records and to examine and consult regarding such records for the purpose of determining my eligibility for the homestead exemption or a possible violation of the homestead laws. Such records shall not contain any federal tax information as defined in I.R.C. 6103 and received from the Internal Revenue Service. I expressly waive the confidentiality provisions of the Ohio Revised Code, including O.R.C. 5703.21 and 5747.18, which may otherwise prohibit disclosure, and agree to hold the Ohio tax commissioner and county auditor harmless with respect to the limited disclosures herein. Except as authorized by law, the parties to which this authority is delegated shall maintain the confidentiality of the information received and the information shall not otherwise be re-disclosed. Signature of applicant Signature of spouse Mailing address Date Phone number E-mail address -2- American LegalNet, Inc. www.FormsWorkFlow.com DTE 105A Rev. 9/16 Please read before you complete the application. What is the Homestead Exemption? The homestead exemption provides a reduction in property taxes to qualified senior or disabled citizens, or a surviving spouse, on the dwelling that is that individual's principal place of residence and up to one acre of land of which an eligible individual is an owner. The reduction is equal to the taxes that would otherwise be charged on up to $25,000 of the market value of an eligible taxpayer's homestead. What Your Signature Means: By signing the front of this form, you affirm under penalty of perjury that your statements on the form are true, accurate and complete to the best of your knowledge and belief and that you are authorizing the tax commissioner and the county auditor to review financial and tax information filed with the state. A conviction of willfully falsifying information on this application will result in the loss of the homestead exemption for a period of three years. Qualifications for the Homestead Exemption for Real Propert