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                                                                                                                                                                    DTE 105H
                                                                                                                                                                    Rev. 10/19
                Addendum to the Homestead Exemption Application for
                Senior Citizens, Disabled Persons and Surviving Spouses
In order to qualify an applicant for the homestead reduction, your county auditor is required to verify an applicant’s modified adjusted 
gross income for the year prior to the year of application. Generally, the auditor is able to verify the modified adjusted gross income of the 
applicant and the applicant’s spouse through use of the portal designed specifically for the county auditor or by a review of the tax return(s) 
of the applicant and the applicant’s spouse for the year prior to the year of application.
You have received this form because the auditor has been unable to verify your income through a review of the portal or tax returns. 
So that the auditor may verify income, please complete the worksheet below. If you are married, the amounts must include income and 
deductions for both you and your spouse. The auditor will use the result for purposes of qualifying you for the Homestead Exemption. The 
estimate of income derived is not an indication of whether or not you or your spouse were required to file income tax returns.
Applicant’s name

Home address

County                                 Tax Year

                Estimated Ohio Modified Gross Income Calculator for Homestead Deduction Only

Income                                                                                                                                                              Amount

  1. W-2 and W-2G income ........................................................................................................................................$ 
 
  2. 1099-R income from retirement plans .................................................................................................................$ 

  3. 1099-DIV and 1099-INT income .........................................................................................................................$ 

  4. Other income (1099-MISC, etc.; do not include Social Security benefits) ..........................................................$ 

  5. Business income (including any farm or rental income, or any income that would be included on 
   Federal Schedules C, E and F). If filing an Ohio tax return, include any business income deducted 
   on line 11 of Schedule A ......................................................................................................................................$ 

   6. Total income (add lines 1-4) ...............................................................................................................................$

Deductions

  7. Uniformed services retirement income, Military Injury Relief Fund amounts or military pay for Ohio 
   residents received while the military member was stationed outside Ohio .........................................................$ 

  8. Disability and survivorship benefits (do not include pension continuation benefits) ...........................................$ 

  9. Unreimbursed long-term care insurance premiums, unsubsidized health care insurance premiums, 
   excess health care expenses, funds deposited into a medical savings account and qualified 
   organ donor expenses ........................................................................................................................................$ 
 
   10. Ohio STABLE and 529 contributions .................................................................................................................$

   11.Total deductions (add lines 7-10) ........................................................................................................................$

  12. Estimated Ohio modified gross income (subtract line 11 from line 6) ................................................................$ 

I declare under penalty of perjury that my (our) income for the prior year is reflected in the information provided above.

Applicant                                      Date

Spouse                                         Date



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                                                                                                                    DTE 105H
                                                                                                                    Rev. 10/19

           Please read this before you complete the front of this application.
Note: If married, amounts on each line must include total income        Line  8:  Enter  disability  and  survivor’s  benefits  to  the  extent 
and deductions from both you and your spouse.                           included  in  federal  adjusted  gross  income  or  that  you  included 
                                                                        on line 2.  To determine if amounts are disability or survivor’s 
Income                                                                  benefits, you should refer to the terms of the plan under which 
Line 1: Enter amounts from box 1 of your Form(s) W-2. Also enter        the  benefits  are  paid. You  may  not  deduct:  1) Temporary  wage 
gambling winnings reported in box 1 of your Form(s) W-2G.               continuation payments; 2) Retirement benefits that converted from 
                                                                        disability benefits upon reaching a minimum retirement age; OR 
Line 2: Enter your retirement income reported in box 2a of your 
                                                                        3) Payments for temporary illnesses or injuries (such as sick pay 
Form(s) 1099-R. The amount in this box is the taxable amount.
                                                                        provided by an employer or third party). Additionally, any amounts 
Line 3: Enter your taxable interest income reported in box 1 of your    payable without the death of a covered individual as a precondition 
Form(s)  1099-INT.  Also  enter  your  ordinary  dividends  reported    are not survivor’s benefits. If you filed an Ohio tax return, enter the 
in box 1a of your Form(s) 1099-DIV. Both of these amounts are           amount from lines 33-36 of Ohio Schedule A. 
taxable.
                                                                        Line  9: Enter your unreimbursed  long-term care insurance 
Line 4: Enter income from any other sources not included above          premiums and unsubsidized  health care insurance  premiums. 
(income  reported  on  Form(s)  1099-MISC,  self-employment             Unreimbursed long-term care insurance premiums are those that 
income, business income). Do NOT include any Social Security            you pay during the calendar year on your own; a company, etc. is 
benefits as they are not taxable in Ohio.                               not paying you back. Medicare Part B is not a deduction because 
                                                                        Social Security is not included as taxable income. Unsubsidized 
Line 5: If  you  have  filed  an  Ohio  Tax  Return,  enter  previously health care insurance premiums are those that are not partially 
deducted business income as reported on line 11 of Ohio Schedule        paid by someone else such as an employer or a retirement plan. 
A (from line 11 of Ohio IT BUS). If you did not file an Ohio tax        Also include on this line any out-of-pocket medical expenses you 
return, enter any business income you received, including income        paid during the tax year and were not reimbursed to you. Some 
that was reported or could be reported on Federal Schedules C,          examples  of  qualifying  expenses  include  costs  for  prescription 
E and F.                                                                medicine and insulin; hospital costs and nursing care; copayments 
                                                                        for medical care; eyeglasses, hearing aids, braces, crutches and 
Deductions                                                              wheelchairs.
Line 7: Enter any military retirement income  if both of the 
following are true: 1) The income is included in federal adjusted       Line  10: Enter any contributions you made to an Ohio 529 
gross income; and 2) The income is related to your service in the       (CollegeAdvantage)  savings  plan  or  any  STABLE  (Ohio ABLE) 
uniformed services or reserve components thereof, or the National       account.
Guard. The term “uniformed services” includes the Army, Navy, Air 
Force, Marine Corps, Coast Guard, the commissioned corps of the 
National Oceanic and Atmospheric Administration, and the Public 
Health Service. If you filed an Ohio tax return, enter the amount 
from lines 26-30 of Ohio Schedule A. 






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