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• eskka/DD▪ "'z1,t 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(MNDay/Yr) Applicant's Social Security Number 04/19/1947 507-56-1188 MYRA J GLAUSE Spouse's Date of Birth(Mo/Day/Yr) Spouse's Social Security Number 1903 W 11TH AVE GRAND ISLAND NE 68803 Legal description of homestead or location and physical description of mobile home: BOGGS&HILL ADD LT 1 BLK 8 Filing Status Q Single ['Married or Closely-related If you were widowed or divorced since Jan.1 last year,answer the following: Spouse's Name: Date of Death: - -Date of Final Decree: e'3 _ • HOMESTEAD EXEMPTION CATEGORIES -' • •Nebraska Schedule 1 must be filed for all categories except Number 5. •See instructions on reverse side for specific requhe`(nents ." �,...,� 1 ® Qualified owner-occupants age 65 and over. p- try 2❑ Veterans disabled by a nonservice-connected accident or illness(Annual certification is required—Form 458B or VA certfication) 1d- 9 7;,„ 3❑ Disabled individuals(see restrictions and instructions for certification requirement). ilk: Gv;. 4❑ Veterans drawing compensation from the Department of Veterans'Affairs because of 100%disability that was service co mcthe unremamed widow(er)(see instructions for certification requirement). `�C rf' 5❑ Paraplegic veteran or multiple amputee whose home value was substantially contributed to by the Department of Veterans Affairs(annual VA certdicb4oni(r ifred). Veteran's Service Dates Beginning , and Ending (Month) (Day) (Year) (Month) (Day) (Year) 1 Do you currently own this residence? IP 'ES ONO 2 Do you currently occupy this residence' ES EINO 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/DayYr) • • Have the household furnishings been removed from your residence? ❑YES ►■ • • Is the residence currently occupied,leased,or rented by another person? t]YES gr, 0 If Yes,who is residing in the residence? 4 II this homestead is owned by a trust,are you residing at this homestead as a beneficiary under the trust instrument?.... 0 YES ZNO 5 If you received a homestead exemption last year,is the preprinted information on this form complete and correct(names, Social Security numbers,birth dale,marital status,exemption category,other owner-occupants,etc p ❑YES JO 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/DayfYr) Social Security Number of my knowledge and belief true and correct.I also declare that I am Under penalties of law,I declare that I have examined v not this form and that it is,to Me best o y Pe soli ed to the Nebraska homestead exemption and have not applied for a homestead exemption elsewhere in 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 ALIEN NUMBER ARE AS Fe` *WS: _ sign AND I AGREE TO PROVII' sPY OF MY USCIS DOCUMENTATION UPON REQUEST. here►Signature pf Applicarff Date Telephone Number FOR COUNTY ASSESSOR'S USE ONLY d,Va Parcel L i I um o�a3 Tax District Number 5 Current ASegtil et/ H sad Property • ❑APPROVED�/J� COMMENTS: _ - _ c _ 7j"`` '//I ((('J1,XT `DISAPPROVED wJ—.. allnialligrala_. . + '� �-a,• _• • Date Received by County Assessor Signature• ' •-sea-or Date -'r Nebraska Department of Revenue Authorized by Neb.Rev.Stat.§§77.3510 and 77-3528 FILE WITH YOUR CO . TY ASSESSOR AFTER FEBRUARY 1 AND BY JUNE 30. Printed with soy ink on recycled paper RETAIN A COPY FOR YOUR RECORDS. Form No9e-295-2009 Rev.1-2013 Supersedes 96-295-2009 Rev.1-2012 •