DTE 105H
                                                                                                                                                                     Rev. 5/14

                    Addendum to the Homestead Exemption Application for 
                    Senior Citizens, Disabled Persons and Surviving Spouses 
                    (Only for applicants who did not fi le an Ohio income tax return for the prior year) 

In order to qualify an applicant for the homestead reduction, your county auditor is required to verify an applicant’s total income for the 
year prior to the year of application. Generally, the auditor is able to verify total income (the income of the applicant and the applicant’s 
spouse), through use of the portal designed specifi cally 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 de-
ductions 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 fi le income tax returns. 
Applicant’s name 

Home address 

County                            Tax Year 

                    Estimated Ohio Adjusted 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 benefi ts) .......................................................... $ 

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

Deductions                                                                                                                           

  6. Uniformed services retirement income and Military Injury Relief Fund amounts ................................................ $ 

  7. Disability and survivorship benefits (do not include pension continuation benefi ts) ........................................... $ 

  8. Unreimbursed long-term care insurance premiums, unsubsidized health care insurance premiums 
    and excess health care expenses ....................................................................................................................... $ 
 
  9. Total deductions (add lines 6-8) .......................................................................................................................... $

  10. Estimated Ohio adjusted gross income (subtract line 9 from line 5) ................................................................... $ 

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

Applicant                                                         Date

Spouse                                                            Date

                                                                                                                               DTE 105H 
                                                                                                                               Rev. 5/14 

               Please read this before you complete the front of this application. 
Note: If married, amounts on each line must include total income   Line 7: Enter qualifying disability and survivorship benefi ts  that 
and deductions from both you and your spouse.                      you included on line 2. Disability benefi ts are benefits paid by an 
                                                                   employee’s disability plan paid as the result of a permanent physi-
Income                                                             cal or mental disability. Survivorship benefi ts are benefits paid from 
Line 1: Enter amounts from box 1 of your Form(s) W-2. Also enter   a qualifi ed survivorship plan as the result of the death of a covered 
gambling winnings reported in box 1 of your Form(s) W-2G.          employee. Do not include amounts that otherwise qualify as re-
                                                                   tirement or pension benefi ts. Upon reaching your plan’s minimum 
Line 2: Enter your retirement income reported in box 2a of your 
                                                                   retirement age, the benefi ts received under that plan become re-
Form(s) 1099-R. The amount in this box is the taxable amount. 
                                                                   tirement benefi ts and are no longer deductible. Contact your plan 
Line 3: Enter your taxable interest income reported in box 1 of    administrator if you are uncertain of the minimum retirement age 
your Form(s) 1099-INT. Also enter your ordinary dividends report-  under your plan. 
ed in box 1a of your Form(s) 1099-DIV. Both of these amounts are 
                                                                   Line 8: Enter your unreimbursed long-term care insurance pre-
taxable. 
                                                                   miums and unsubsidized health care insurance premiums. Unre-
Line 4: Enter income from any other sources not included above     imbursed long-term care insurance premiums are those that you 
(income reported on Form(s) 1099-MISC, self-employment in-         pay during the calendar year on your own; a company, etc. is not 
come, business income). Do NOT include any Social Security         paying you back. Medicare Part B is not a deduction because 
benefi ts as they are not taxable in Ohio.                          Social Security is not included as taxable income. Unsubsidized 
                                                                   health care insurance premiums are those that are not partially 
Deductions                                                         paid by someone else such as an employer or a retirement plan. 
Line 6: Enter uniformed services retirement income that you        Also include on this line any out-of-pocket medical expenses you 
included on line 2. Also enter any taxable portion of military in- paid during the tax year and were not reimbursed to you. Some 
jury relief fund amounts that you received. Uniformed services     examples of qualifying expenses include costs for prescription 
retirement income includes amounts received as retired person-     medicine and insulin; hospital costs and nursing care; copayments 
nel pay for service in the United States Army, Navy, Air Force,    for medical care; eyeglasses, hearing aids, braces, crutches and 
Coast Guard, or Marine Corps uniformed services or reserve, or     wheelchairs. 
the National guard, or received by the surviving spouse or former 
spouse of such a taxpayer under the Survivor Benefi t Plan on ac-
count of such taxpayer’s death.