Homestead Credit Application

Homestead Credit Application for Senior Citizens & Disabled Persons

Office of State Tax Commissioner - SFN 24757 (10-2024)
File application with the local assessor prior to March 7 of the year for which the credit is requested.
Please use prior year income and out of pocket medical expenses
For the Year of*
Applicant Information
Applicant's Name*

First NameLast Name
Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Marital Status*

MarriedSingle
Property Information
Parcel Number
Lot
Block
Addition
Dickinson
Which of the following would best describe the type of ownership of the homestead property?*

Is recorded in your (and spouse's) name as ownerIs being purchased by you under a contract for deedIs held in joint tenancy with one other than spouseIs held under a life estate propertyIs held in a revocable trust
% Owned*
Does this property receive the Farm Residence Exemption?

YesNo
Net income from Social Security benefits (Gross benefit minus Medicare premium): $*
Income from wages, salary, etc. (From Form 1040 or 1040-SR, line 1z):*
Income from taxable interest and dividend income (From Form 1040 or 1040-SR, lines 2b and 3b): *
Income from all other sources (From Form 1040 or 1040-SR): *
Income from IRAs, pensions, and annuities (From Form 1040 or 1040-SR, lines 4b and 5b):*
Capital gains and losses (From Form 1040 or 1040-SR, line 7):*
Dependent's total income from all sources*
Total Income from all Sources
Total amount of health and hospital insurance premiums (Exclude Medicare): *
Prescription medicine and drugs:*
Doctor, dentist, and hospital costs: *
Hearing aids, eyeglasses, dentures, etc.:*
Number of out of town, overnight hotel stays for medical care.*
Mileage Traveled for Medical Care*
Transportation Costs for Medical Care: (67 Cents Per Mile)
Nursing home care costs and/or home nursing care costs: .*
Total Medical Expenses*
Income for all sources excluding medical Expenses (Total Income - Total Medical)*
I declare under the penalties of N.D.C.C. § 12.1-11-02, which provides for a Class A misdemeanor for making a false statement in a governmental matter, that this return, including any accompanying schedules and statements, has been examined by me and to the best of my knowledge and belief is a true, correct, and complete return. I am willing to furnish proof of age, income and assets if requested to do so by someone authorized to administer this assessment credit. I reside on the property described in this application and I hereby claim the Homestead Credit on this property as provided for in N.D.C.C. § 57-02-08.1.
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Homestead Credit Application for Senior Citizens & Disabled Persons

Applicant Information

Property Information