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"�°�~ Nebraska Hamestead Exemptian Application or Certificatian of 5ta#us �oRM <br /> Ne6raska Department of <br /> REVENUE • Nebraska Schedule I-Income Statement must be filed with Yhis form. 4�Q <br /> • See inatructions on reverse side. y <br /> ` �^File with your county assessor after February 1 and by June 30. PLEASE p0 NOT WRITE 1N THIS SPAC� � <br /> PLEASETYPE�OR PRINT <br /> County ^ County Numbr:r <br /> tiALl, 4p <br /> _.�� _.,. _,_...�,..,_._. _....._. <br /> Applicani's Social 5ecurily Number Applicanfs Oate oi Bir�h(Mo/Day/Yr) _�� _ AI�PLICANT'S NAME AND ADDR�SS _� <br /> 508-60-6685 04/07/1949 ,fAY�'.IE.A QECKER <br /> Spou5e's Social Ser,urity Number Spouse's Date of 6irth(MO/pay/Yr) <br /> 2Q1$ PIONEER BLVD <br /> Legal description of homestead or location and physical description ot mobile home G RAN D I SLAN D, N E 688p 1 <br /> qr residence on Ieased land: <br /> PARK-VIEW SUB LT 5 BLK B <br /> Fil+ng 5tatus � { <br /> �Single Q Married or Closely-related <br /> if you were widowed vr divorced since January 1 tast y�ar,please <br /> 1 (?o you currently own and occupy this residence? �Y�S �NO ans�ver the following: <br /> 2 If you are currenUy residing in a nursing home, Spouse's Name: �` <br /> please answer the5e questions_ Date of Death- Oaie of Final becree:..... <br /> _._....----- <br /> •What date did you enter the nursing home? ----�---------- <br /> (rvto/l7ay/vr) HOMESTEAD�XEMPTION CATEGORIES <br /> •Nave the househoid furnishings been removed •Nebraska 5chedule T must be filed forall categories except Number S. <br /> from your residence? Q YES Q NO •See instructions on reverse side for specific requirements. <br /> -Is the residence currenily occupied 6y <br /> another person? �YES �NO 7 ❑ �ualified owner-occupants age 65 and over. <br /> If Yes,who is residing there? 2 [] Veterans disabled by a npn-servi�e connected accident or illness <br /> 3 If#his homestead is awned by a trust,are you residing (Annual certification is required—Form 458B or VA certification). <br /> at this homestead as a beneficiary undsr the 3 Disabled individuals(see instructions for certification requirementj. <br /> trust instrum�nt? �YES �NQ <br /> 4 If you received a homestead exemption last year, 4 Veterans drawing compensatibn from the Department of Veterans' <br /> � is the preprinted intormation on thi5 torro complete Affairs because of 100°/disability that was servic�connected,or the <br /> and correct(names,5ocial Security numbers, unremarried widow(er)(see instructions for certification requirement)_ <br /> birlh date,marital status,exemption category, 5 [] The value of a home substantially contributed to by ihe Depariment <br /> other owner-occupants,etc.)? �Y�S �NC7 of Veterans'Affairs(annual VA certification required). <br /> If No,piease indicate the correct information in the appropriate area. <br /> --...�..�. ____ _—_..._--- — <br /> OTHER OWNERS WHO OCCl1PYTHE RESIDENCE(Attach list if necessary.) <br /> •Ne6raska Schedule I---Income Statement must he filed for each owner-occupant(DO NOT repeat applicant and spouse.) <br /> ..._..._. _..... _ <br /> Narne Relationship to Appiicant pate af Birth(nnWpay/Yr) � � _�� b <br /> ._......�....__.__ -- -----....--- ----.._ _ JUL � 3 2011 <br /> . tlnder penalties af law,I declare that I have examined This form and thai it+s,to the best of my knowledge and belief,vue an t. t � <br /> 1 am entitled tp the Nebraska homestead exemptior�and have not applied tor a homestead exemption elsewhere in ihe state.Fu s •������� <br /> �I am a citiz,en of Ihe Uni[ed States. �������B�ASKQi <br /> �Ia�qualitiedalienundertheFederallmmigrationandNationalityACl.Myimmigrationstafusandaliennumberareaslnllows: ,,,,� <br /> ��g n e ro provide a copy of my USCIS documer�tatipn upon requesL <br /> � '�%i� �. �� _�___-. � ' � <•�/ _�° - ���� � <br /> here 5�r� �.a,r� ..�_�.__ � <br /> e oi 1� plicant �^ Date Tele hone Numbcr <br /> P�rce�n Id.. ._ _..,�._.. p -___�._ <br /> FQR COUNTY ASSESSpR'S USE ONLY <br /> �...,_. ..W._ --- _.....,.._ <br /> entifrcation Number Tax Uistrict Numper Current Assessed Value ot the liomestead Property � <br /> .... � � � <br /> _,.___ �C.c� � �� <br /> - . ._------ -- <br /> �. ..w m,.--- <br /> �_ Veteran's Service Dates <br /> n Service bates eeginning ,_ and Gnding <br /> ._�._.._._._... <br /> APPROVED COMMENTS:�;�,i,.�� �, ' � � �,�'f � <br /> _ [ i-�r9 � r.r,i• <br /> n ti <br /> �_ � -- <br /> DISAPPROV�[] -- - - <br /> , y�. <br /> date Received by Cbunty Assessor �Signature o u ly ssessor �� �� v_ µ "'�' p������"'�` <br /> Nebraska Oepanrrient of Hevenue � Authorized by Neb.Fiev.stai.§§77-3;7o and 77-3526 <br /> FILE WITW YpUR CO TY ASSESSpR AFTER FEBRUARY 1 AND BY JUNE 30. <br /> R�7AIN A CDPY�QR YOUR RECORC]S. Form No.sc 2ss-2op9 Rev.i-zot�Supersedes s�-zs�zoos <br />