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rl J� FORM '�" Nebraska Hamestead Exemption Application or Certification of Status Nebraska l7epartmeM of 45 8 REVENUE • Ncbraska Schedule 1-Income Statement must be filed with this form. — � See instructions on reverse side. _ -- - -'— '— PL�ASE��NOT W Fi1TE IN 7HIS SPACE File with your county assessor after February 1 and by June 30. _—_.. __—_-�. �, _ , r PLEASE TYi'E OR PRINT � ---• _. .,.. _.. County � County Number HALL 4� � _.. . _..—...... _.. —._. -- - - -- - _ A�iplicants 5ocial Security Number ApplicanYs Date of eirth(Mo/Qay/Yr) APWL!CP.N7'S PlAME P.ND.4DDRE _ 506-30-3851 03/12/1931 V�I��HiV� ❑ IV1��t�'t��/ _ —.. . _ - Spouse's Social Security Number Spouse's Date ot Birth(Mo/�aylYr) DELORES M MORROW 340-26-3052 5l11/1934 —9-or res dence oln leased la�dead or�ocation and Pri � � �0833 S �QTH RD P ysical description of mobile home DONIPHAN, N� 68832 SOUTH PLAT7E TWP LTS 3&5 MLb&SW 1/h 4-9-10(224 AC) _._____ — Filing Status QSingle O Married or Closely-related .. _.,. __—,- __ ._ _ If you were widowed or divorced since January 1 last year,please 1 Do you currently own and occupy this residence? Q YES �NO answer the following: 2 If you are currently residing in a nursing home, 5pouse's Name:__. - - please answer thes�questions: Date of Qeath:—.... _ �ate of Final Decree: _ _. _. ,_ __ .. __.. ... _ •What date did you enter the nursing home? __.—.. — (Mo/�ay/Yr) HOME57EAD EXEMPTION CATEGORIES •Have the househpld turnishings been removed •Nebraska Schedule I must be filed tor all categories except Nurriber 5. from your residence? �YES Q NO •See instructions on reverse side for specific requirements. •�s the residence currently occupied by another person? QYES �NO 1 ❑ Qualified owner-occupants age 65 and over. If Yes,who is residing Yhere? _ __ 2 ❑ Veterans disa6led by a non-service connected accident or illness 3 If this homestead is owned by a trust,are you residing (Annual certification Is required—Form 458B or VA certificatlon). at this hamestead as a beneficiary under the g � Disabled individuals(see instructions for certiticatipn requirpment). trust instrument? OYES �Nd 4 If you received a homestead exemption last year, 4 � Veterans drawing compensation from the Department ot Veterans' is the preprinted information on this form complete Affairs because af 100%disability that was service connected,or th� and correct(narnes,Social Security numbers, unremarried widow(er)(se s •i f ic ernent). birth date,marital status,exemption category, 5 ❑ The value of a home subs�n �� rtment other owrier-occupants,etc.)? �YES O NO of Veterans'Affairs(annual VA certifir.ation required). If No,please indicate the correct information in the appropna.e area. �� n _t?ni� _....- 07HER OWNERS WHOTOCCUPYTHE RE ~ �y� ..,. _. . --- lJl.. V fD -' SI�ENC�(Attach list if necessary.) •Nebraska Schedule I—Income Statement must be filed for each owner-occupant(DO NOT re � py(i �� � _. -. - - .. __. __.__ p -- ._ y ^ Name `� ,L�� ef Relationship to Appliaant bate of Birth(nno/�ay _ p � - _ - I arrUe neled to the Nebraskal home i�adte emption and haveynot appl ed forla15,��the�est o(rny knowledge and belicf,true and correct.I alsn dec are t ia hpmestead exemption eISP.wherc in the stale.Further,I atlest as follows: �I am a citizen of the United Slates. �IamaqualificdalienundertheFederallmmigrationandNa[ionalityAc[.Myimmigrationstatusandaliennumberareasfollows:_.,. „ and I agree to provide a copy o1 my IJSCIS document n upon request. s�g n ,��,�` • �i-�`��.C�� . 1--�"��.�'-1`�""-,.'.. _. _ _ _ �� Signature of Applicant Date Tclephnne lvurnber __ _ _ _ _ _. _._ . _. _._,, _... _ - FOR COUNTY ASSESSdR'S USE ONLY _ , � _. _ _.. _. . _ �.... - -. Par � Ur Localior I nli6Cation, urn r Tax Qistrict Nun�ib Gurrent Assessed Value u1 the Hornestead roper y ��-�'"��- ---� _ .-'��._ .c Dates --... - - - CVeteran s Servi e ❑Service C]ates E3eginning___., _and tnding_ _ � . -._— � ' c` P.�v,fc„�,�—.�.....t-'7 i 3.�,.��. :�f� ❑APPRbV�D COMMENTS: _ � � -� - - , �� •� "�-''�C. • �. -�}'`".., _ „ �DISAPPROVED _ . _ , , �.. > �..��`�:_ _ _ �--�� �ate Rer.eived by County Assessor Signature of nty Assessor _ ._� ... - - � -- ---� -�� f' -� Autherized by NC6.Rev.SIaL§§77-3510 and 77-3528 Nebraska�epaliment pf f7evenuC FII�E WITH YOUR G � NTY A55ESSOfi AFTEFi�EBRUARY 1 AND BY JUNE 30. RETAIN A CQPY FOR YOUR RECORpS. Form No.sc-zs5�2�os He�,i-2o��suPersedcs ss-zss zoos