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ska Department of Nebraska Homestead Exemption Application or Certification of Status FORM REVENUE • Nebraska Schedule I-Income Statement must be filed with this form. 458 • See instructions on reverse side. File with your county assessor after February 1 and by June 30. PLEASE DO NOT WRITE IN THIS SPACE PLEASE TYPE OR PRINT County HALL APPLICANT'S NAME AND ADDRESS Applicant's Date of Birth(Mo/Day/Yr) Applicants Social Security Number J 04 / 07 /1949 508606685 JAYNE A DECKER Spouse's Date of Birth(Mo/Day/Yr) Spouse's Social Security Number 2018 PIONEER BLVD ,---7--7-- ____ GRAND ISLAND, NE 68801 Legal description of homestead or location and physical description of mobile home: PARK VIEW SUB LT 5 BLK B Filing Status ® Single ❑Married or Closely-related If you were widowed or divorced since Jan.1 last year,answer the following: JUL /... Spouse's Name: U Date of Death:� 1'.L)Q Date of Final Decree: `{ 2013 HOMESTEAD EXEMPTION CATEGORIES . - ,. •Nebraska Schedule I must be filed for all categories except Number 5. •See instructions ett,reverse side for specific requirements. .. 1 ❑ Qualified owner-occupants age 65 and over. 2❑ Veterans disabled by a nonservice-connected accident or illness(Annual certification is required—Form 458B or VA certification). , 3® Disabled individuals(see restrictions and instructions for certification requirement). 4❑ Veterans drawing compensation from the Department of Veterans'Affairs because of 100%disability that was service connected,or the ' unremarried widow(er)(see instructions for certification requirement). 5 ❑ Paraplegic veteran or multiple amputee whose home value was substantially(AA itributed to by the Department of Veterans Affairs(annual VA certification required). Veteran's Service Dates Beginning , and Ending , (Month) (Day) (Year) (Month) (Day) (Year) 1 Do you currently own this residence? RYES ❑NO a O9 2 Do you currently occupy this residence? RIPS ES ❑ NO 3 If you or your spouse are currently residing in a nursing home,please answer these questions: • What date did you or your spouse enter the nursing home? / / (Mo/Day1Yr) • Have the household furnishings been removed from your residence? ❑ YES ❑ NO • Is the residence currently occupied,leased,or rented by another person? ❑ YES ❑ NO If Yes,who is residing in the residence? 4 If this homestead is owned by a trust,are you residing at this homestead as a beneficiary under the trust instrument?.. . . ❑ YES ❑ NO is the preprinted information on this form complete and correct names 5 If you received a homestead exemption last year, s th p p p (names, Social Security numbers,birth date,marital status,exemption category,other owner-occupants,etc.)? ❑YES ❑NO If No,please indicate the correct information in the appropriate area. OTHER OWNERS WHO OCCUPY THE RESIDENCE(Attach list if necessary.) •Nebraska Schedule I—Income Statement must be filed for each owner-occupant(DO NOT repeat applicant and spouse.) Name Relationship to Applicant Date of Birth(Mo/Day/Yr) Social Security Number / / / / Under penalties of law,I declare that I have examined this Corm and that it is,to the best of my knowledge and belief,true and correct.I also declare that I am emnl to the Nebraska homestead exemption and have not applied for a homestead exemption elsewhere in the state. I AM A CITIZEN OF THE UNITED STATES. ❑ I AM A QUALIFIED ALIEN UNDER THE FEDERAL IMMIGRATION AND NATIONALITY ACT.MY IMMIGRATION STATUS AND A N NUMBER ARE AS FOLLOWS: t I AGREE TO PR VIDE A COPY OF MY USCIS DOCUMENTATION UPON REQUEST. sign :'i>ida GL j6 /3 3a44/2 - /a8.3 here Sign. re of pplicant Date Telephone Number FOR COUNTY ASSESSOR'S USE ONLY Parcel or Location ID Number Tax District Number Curren sensed Vqr ol7he romestead Property 400 @75571 5 (��((//�� (xJ�/ APPROVED COMMENTS: r _ �).%. ..--z.— -1� jai{ Dar .le�riv y County ssessor Sig lure of ssessor Date Nebraska Department of Revenue • Authorized by Neb.Rev.Stat.§§77-3510 and 77-3528 FILE WITH YOUR COU -TY ASSESSOR AFTER FEBRUARY 1 AND BY JUNE 30. Printed with soy ink on recycled paper RETAIN A COPY FOR YOUR RECORDS. Form No.96-295-2009 Rev.1-2013 Supersedes 96-295-2009 Rev.1-2012