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art----z..- FORM Nebraska Department E Nebraska Homestead Exemption Application or Certification of Status REVENUE • Nebraska Schedule I-Income Statement must be filed with this form. 458 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 Applicants Date of Birth(Mo/Day/Yr) Applicant's Social Security Number OFILIA ARELLANO 08 / 21 /1932 507385315 Spouse's Date of Birth(Mo/DayiYr) Spouse's Social Security Number 903E 5TH / / GRAND ISLAND, NE 68801 Legal description of homestead or location and physical description of mobile home: EVANS ADD LT 5 BLK 14 i Filing Status ®Single ❑Married or Closely-related a'� *3 Wiz; If you were widowed or divorced since Jan.1 last year,answer the following: 2"` '' '"" t sr _-" Spouse's Name: Date of Death: Date of Final Divorce Decree: JUL 1 7 ?f1SI . Homestead Exemption Categories •Nebraska Schedule I must be tiled for all categories except Numbers 4 and 5. •See instructions on reve iit, ,''•- •• ;:ci• r;•uirecg:.•. 1 ®Qualified owner-occupants age 65 and over. &N or 2❑Veterans totally disabled by a nonservice-connected accident or illness(Annual certification is required—Form 4506or wi a �lbn)) 1,WOiU? 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❑The unremarried widow(er)of a serviceperson who died while on active duty(VA certification required). 7❑Individuals who have a developmental disability(Form 458B is required). If category 2,4,5,or 6 are checked above,enter veteran's service dates. Veteran's Service Dates Beginning , and Ending , (Month) (Day) (Year) (Month) (Day) (Year) 1 Do you currently own this residence'? ❑YES ❑NO 2 Do you currently occupy this residence? IN 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 ❑NO • Is the residence currently occupied,leased,or rented by another person? ❑YES ❑NO If Yes,who is residing in the residence? 4 Is this homestead owned by a trust? 11 YES ❑NO • If Yes,are you residing at this homestead as a beneficiary under the trust instrument? YES ❑NO 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.)? r 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(MoIDay/Yr)' Social Security Number / / / / Under penalties of law,I declare that I have examined this form and that it is to the best of my knowledge and belief,true and correct.I also declare that I am entitled to the Nebraska homestead exemption and have not applied for a homestead exemption elsewhere in the state. IF 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 sign /fa;qs follows: nd I gr�e.tp provide a copy of my USCIS documentation upon request. here Signal� of P� 7.2_ C/ J 0 ,y/7 2'r3a pry.-r, Date Telephone umber FOR COUNTY ASSESSOR'S USE ONLY Parcel or Location ID Number Tax District Number Cur nt Ass'ssadtr lue Homestead Property 400128950 5 vV�, ❑Approved Comments: - - ,._ — _ `. .`. -_ Disapproved . �.._�� _ _‘I 1 - tZ- t. . ,1! _t � Date Received by County ssessor Signature of Cou i -: •r Da a`�' _(C� Nebraska Department of Revenue File with your CO t assessor after February 1 and June 30. Authorized by Neb.Rev.Stat.§4 773510 and]73528 y y rY by Form No.96-295-2009 Rev.1-2015 Printed with soy ink on recycled paper 14-tain a copy for your records. supersedes 96.295-2009 Rev.1-2014