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Nebraska oe�panmeen,of Nebraska Homestead Exemption Application or Certification of Status FORM REVENUE • Nebraska Schedule 1-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) Applicant's Social Security Number 05/24/1947 506-60-8523 RICHARD W.LORANCE Spouse's Date of Birth(Mo/Day/Yr) Spouse's Social Security Number BARBARA A LORANCE 03/22/1952 505-60-4834 809 N HOWARD Legal description of homestead or location and physical description of mobile home: GRAND ISLAND NE 68803 WEST VIEW LT 9 BLK 8 x Filing Status 0 Single I]Married or Closely-related If you were widowed or divorced since Jan.1 last year,answer the following: "LI' Spouse's Name: Date of Death: Date of Final Decree: r�/j HOMESTEAD EXEMPTION CATEGORIES • •Nebraska Schedule I must be filed for all categories except Number 6 •See instructions on reverse side for-s15e0hc regdlrements. 1 ® Qualified owner-occupants age 65 and over. 2❑ Veterans disabled by a nonservice-connected accident or illness(Annual certification is required—Form 4568 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 contnnbuted 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? K V S ONO 2 Do you currently occupy this residence? YYpp GES ONO 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/Day/Yr) • Have the household furnishings been removed from your residence? ❑YES Y1NI • Is the residence currently occupied,leased,or rented by another person? 0 YES yEAb 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 v�f0 5 If you received a homestead exemption last year,is the preprinted information on this form complete and correct(names, Social Security numbers,birth date,marital status,exemption category,other owner-occupants,etc)'1 ❑YES 10 If No,please indicate the correct information in the appropriate area. OTHER OWNERS WHO OCCUPY THE RESIDENCE(Attach list if necessary.) *Nebraska Schedule 1—Income Statement must be filed for each owner-occupant(DO NOT repeat applicant and spouse.) i Name Relationship to Applicant Date of Birth(MG/Day/Yr) Social Security Number U r penalties of law,I declare that I have examined his form and that it is,to the best of my knowledge and belief,true and correct.I also declare that I am anti to the Nebraska homestead exemption and have not applied for a homestead exemption elsewhere in the state. I AM A CITIZEN CF THE UNITED STATES. ❑I AM A QUALIFIED ALIEN UNDER THE FEDERAL IMMIGRATION AND NATIONALITY ACT.MY IMMIGRATION STATUS AND ALIEN NUMBER ARE AS FOLLOWS: D I GI OVIDE A PY OF MY USCIS DOCUMENTATION UPON REQUEST. oac sign �� ,c-Z• ��1 3 f -)0 7 � here Signature of Applicant Date Telephone Number FOR COUNTY ASSESSOR'S USE ONLY Parc o L n Tax District Nu-_= Current Asses of Lir lea Property ❑APPROVED COMMENTS: .�yf' S..-`: a,__, _. — + . _a_.- t' : _ — _ ..r, - _ -r. DISAPPROVED t._- tE� – • __..—. .an' -- w '}7 it, l"'-1 i"! '.'�► Itlx: !'�' 'Z-1S--1, Date Received County—Assessor Signature of Co• essor Date Nebraska Department of Revenue Authorized by Neb.Rev.Stat.N77-3510 and 77-3529 FILE WITH YOUR COUN ASSESSOR AFTER FEBRUARY 1 AND BY JUNE 30. Primed with soy ink on recycled paper RETAIN A COPY FOR YOUR RECORDS. Form Na.9s-295-2009 Rev.1-2013 Supersedes e6-255-20o9 Raga-2012