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Nebr,nk•bepanmem9( Nebraska Homestead Exemption Application or Certification of Status FORM REVENUE • Nebraska Schedule I-Income Statement must be filed with this form. 4558 Ale 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 Dale of Birth(Mo/Day/Yr) Applicant's Social Security Number Michael D. Paulick 03/15/1951 505-62-2571 • Spouse's Date of Birth(Mc/Day/Yr) Spouse's Social Security Number Barbara E. Paulick 03/14/1950 510-56 3664 U`-' 7 e✓ Legal description of homestead or location and physical description of mobile home: Qrafl P n I , fNt-' Ogg() ► tviorns Ll, . Li- Lily 1�]fi�{'y�` {//e Status `' '- 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 Divorce Decree: JUI t 3 2015 Homestead Exemption Categories •Nebraska Schedule I must be filed for all categories except Numbers 4 and 5. •See instructions on reverse side for specific requirements. 1 ®Qualified owner-occupants age 65 and over. HALL . '.-.•9 - 2❑Veterans totally disabled by a nonservice-connected accident or Illness(Annual certification is required—Form 4 (rA gtir4'f( ;ion) € 1fit 3®Disabled individuals(see restrictions and instructions for certification requirement). 4❑Veterans drawing compensation from the Department of Veterans'Affairs because of 100%service-connected disability,or the unremarried widow(er) (VA certification required;see instructions for certification requirement). 5❑Paraplegic veteran or multiple amputee whose home value was substantially contributed to by the Department of Veterans Affairs(annual VA certification required). 6 p The unrentarried widower)of a serviceperson who died while on active duty(VA certification required). 7❑Individuals who have a developmental disability(Form 458B is required). It category 2,4,5,or 6 are checked above,enter veteran's service dates. Veteran's Service Dates Beginning , and Ending , (Month) (Day) NO (Month) (Day) (Near) 1 Do you currently own this residence? • YES al NO 2 Do you currently occupy this residence? ❑• YES ❑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/Day/Yr) • Have the household furnishings been removed from your residence' ❑YES Q NO • Is the residence currently occupied,leased,or rented by another person? ❑YES I]NO • If Yes,who is residing in the residence? 4 Is this homestead owned by a trust? ❑YES D NO • If Yes,are you residing at this homestead as a beneficiary under the trust instrument? ❑YES ❑ NO • 5 II 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.)? D 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(Me/Day/Yr) Social Security Number Underipenalties of law,I declare that I have examined this form and that it is,to the best of my Imowledge and belief,true and correct I also declare that I am entitled to he Nebraska homeste:.exemption and have not applied for a homestead exemption elsewhere in the state. • i t� 1 am a citizen of the U ted .tes. • .m a • -lifts, . 'en under th Fe•-ml�1 igration and Nationality Act.My immigration status and alien number are sign fot ts: / / and I agree to provide a copy of my USC1S documentation upon request. �dy �(� • Fir and 308-380-632151 here' Signatur-ofA.• :nt Date Telephone Number I. FOR COUNTY ASSESSOR'S USE ONLY 1 P _ n tpnyg Nu r/�r> / Tax District Number /r—"' Current As �elaluev6�(1(11y�me�tead Fop, ❑Approved ( f6c�1i%l[//) Comments: 3• 3. J cr o-' .-y,. (��l(l/�n1 t-i_•`(t : I- , a:: _r aDisapproved _ _ . _ , 7 - i 3-- 1 ► i!,. ii1G Date Received by County Assessor Signature of County t-:ssor Date Nebraska Department et Revenue File with your coun • :ssessor after February 1 by June 30.Authorized by Nett�'Stat.g TA351a end 77.3528 Y rY bf Fran Na 98-295.2009 Rev.2-2015 n.:•row.,an•rv,Jn•,,.,.v-imbn a., . RPTain a ennv Mr vnr it rarnrrts- Si innm,mc wcagF PAY 1.9ma