07/28/2015 - Laserfiche WebLink

Home Browse Search

�_ Nebraska Department of Nebraska Homestead Exemption Application or Certification of Status FORM RED • Nebraska Schedule 1-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 Applicant's Dale of Birth(Mo/Day/Yr) Applicant's Social Security Number MARLENE HURLEY 11 / 28 /1938 507424836 Spouse's Date of Birth(Mo/Day/Yr) Spouse's Social Security Number 3120 W 18TH / / GRAND ISLAND, NE 68803 Legal description of homestead or location and physical description of mobile home: WESTERHOFF'S FIRST SUB W 61'OF E 74' LT 12 BLK 1 Filing 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: _ Dale of Anal Divorce Decree: _ Homestead Exemption Categories hh •Nebraska Schedule I must be filed for all categories except Numbers 4 and 5. •See instructions or}heftarseside for specific requirements. 1 ®Qualified owner-occupants age 65 and over. 2❑Veterans totally disabled by a nonservice-connected accident or illness(Annual certification is required—Form 4588 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%servlce-rhopnecte'f asability or the, r n�ried widow(er) (VA certification required;see instructions for certification requirement). !��y'�y,��,,�?f . V SS20/J '#s-ay 5❑Paraplegic veteran or multiple amputee whose home value was substantially contributed to by the DeparlPfi�Q�'poterans Affair (aannual VA certification required). 6❑The unremarried widow(er)of a serviceperson who died while on active duty(VA certification required). t�.rre;,. 7❑Individuals who have a developmental disability(Form 4588 is required). If category 2,4,5,or 6 are checked above,enter veteran's service dates. Veteran's Service Dales Beginning , and Ending -4 , (Month) (Day) (Year) (Month) ( (Year) 1 Do you currently own this residence? ES ❑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 ❑ 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? ❑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.)? .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 / / / / tJ 4 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 jrenntj'iiSto the Nebraska homestead exemption and have not applied for a homestead exemption elsewhere in the state. I am a citizen of the United St.tes. ❑ I am a •ualdle• ien un•/ e Fede . m •igration and Nationality Act.My immigration status and alien number are sign - - �/- and I agree to provide a copy of my USCIS oct atpn on y hereeziynz/ dr.,./A (yam //i :n t'7ri fi .7- ' '' Date Telephone Number FOR COUNTY ASSESSOR'S USE ONLY Parcel or Location ID Number y i ax District Number Curren( ( 'VaWJ eFJ stead Property 400112515 5 ❑Approved Comments: _ _ . _ - - _` - - ^ _ _ -- RDisapproved = r' Date Aecewed by County Assessor Signature of sses Date ( - tJ - Nebraska Department of Revenue File with your •unt assessor after February 1 and by June 30.Authorized by Neb.Rev,Stat.§§773510 and 77-3528 Y Y rY Y Form No.96-295-2009 Rev.1-2015 °tinted with soy ink on recycled paper Retain a copy for your records. Supersedes 96.295-2009 Rey.1-2014