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Nebraska oep4 men"V.; Nebraska Homestead Exemption Application or Certification of Status FORM RE Y G'i; U" •Nebraska Schedule I-Income Statement must be filed with this form. A G O PUOPERrynss)SSMF,F a Application for Transfer must be filed by August 15 if moving to a new homestead. YJv Please Do Not Write In This Space File wl t, .u1' county assessor after February 1 and by June 30. p• ..� ' Please Type or Print County HALL Applicant's Name and Address Applicant's Date of Birth(Mo/Day/Yr) Applicant's Social Security Number CAROL A FREDRICK 06 / 25 /1942 505580669 10400 W AIRPORT RD Spouse's Date of Birth(Mo/Day/Yr) Spouse's Social Security Number CAIRO, NE 68824 Legal description 1 homestead or location and physical description of mobile home: MAYFIELD TWP C FREDRICK SUB LT 1 (1.97 AC) Filing Status RECEIVED ®Single ❑Married or Closely-related If you were widowed or divorced since Jan.1 last year,answer the following: Spouse's Name JUL 0 5 2016 Date of Death Date of Final Divorce Decree Homestead Exemption Categories eerp1��lltt,�t' SOR •Nebraska Schedule I must be filed for all categories except Numbers 4 and 5. •See instructions on r44@k6 Sialbl ....„1, „g;, ,;. r-nts. 1 ®Qualified owner-occupants age 65 and over. G^• i 1 1 ' 'I, • r- 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%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 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? RYES ❑ NO 2 Do you currently occupy this residence? [V 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/DayfYr) • • Have the household furnishings been removed from your residence? ❑YES n NO • • Is the residence currently occupied,leased,or rented by another person? ❑YES 1 NO If Yes,who is residing in the residence? 4 Is this homestead owned by a trust? ❑YES NO NO • If Yes,are you residing at this homestead as a beneficiary under the trust instrument? ❑YES IJ 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 dates,filing status,exemption category,other owner-occupants,etc.)? 'YES ❑NO • If No,please indicate the correct information in the appropriate ro riate area. Other Owners Who Occupy The Residence(Attach list if necessary.) NO •Nebraska Schedule 1—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 / / / / 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. II 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 a ollows: and I agree to provide a co sign (W4_ a a� 9 P copy of my USCIS documentation upon request. hpCe 'SignatureofApplican[ to - ) 9_2c/& ?o6---- `14--//9g7 Date Telephone Number FOR COUNTY ASSESSOR'S USE ONLY Parcel or Location ID Number Tax District Number Current Assessed Value of the Homestead Property 400424967 145 ❑Approved Comments: % • _ t. _ Disapproved __ - �_ _�- _ _ ti - a... - - Date Received by County Assessor Signature .unty As -ssor Date Nebraska Department of Revenue Authorized by Neb.Rev.Slat.§§77-3510-14 and 77.3528 File with y. r county assessor after February 1 and by June 30. Form No 96-295-2009 Rev.1-2016 'tinted with soy ink on recycled paper Retain a copy for your records. supersedes 96-295-2009 Rey 1-2015