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3083810521 Legal Aid of Nebraska GI 02:40:18 p.m. 10-05-2018 215 Nebraska Homestead Exemption Application or Certification of Status FORM 458 Good Lira GreatServica •Nebraska Schedule I-Income Statement must be filed with this form except for categories 4 and 5. AA•1 A ea•.r.ors.e..a •Application for Transfer must be filed by August 151f moving to a new homestead. LV'V File with your county assessor after February l and by June 30. Please Do Not Write In This Space Please Type or-Print Courtly HALL Applicant's Name and.Address Applicants Daises Bkt(Moioayfrr) AppicanrsSocialSeaxityNumber ANNMVREDEVELD 10 /30 / 1944 480-54-5524 Spouse's Dale of Birth(MoiOayNr) Spouse's Social Security Mrmber Legal descriptor'of homestead or physical description at mobile Noce: 5100 HUSKER HWY ENTERTWP PT SE 1/4 SE 11428-11-10 (I.IO AC) ALDA,NE 68810 Fling Status ®Single ❑Married or Closely-related If you were endowed or divorced since Jan.1 last year,answer the following: Spouse's Name E ti e`` 1 q-• Date of Death __Dated Final Divorce Decree Homestead Exemption Categories •Nebraska Schedule I must be fled for all_atagodes r•rcept Numbers 4 amt_. •See insttructdos en/case cite for suer-r flex Al9r5nt2018 1E]Qualified owneroccupants age 65 and over. 2❑Veterans totally disabled by a nonservice-connected acddent or illness(Form 458B or VA certification). HALL �Ci Y i'r , 3 Disabled individuals(see restrictions and instructions for certification requirement). pp (� ccII �I'i pp'``:��;,��`S` "OR 4❑Veterans hawing compensation tom the Department of Veterans Affairs because of 100%service-connected disability or ow tiurbYfih ✓;H-{virinvy(erg A0 KA NA certification required;see instructions for certification requirement). 5❑Paraplegic veteran or miuple amputee whose tome value was sWStanteilycintriouted to by the Department of Vetera,sAeairs(emual VA certification required). 6❑The uiremanled widower)of a serviceperscn who died while on active duty NA certification required). 7❑lnaviduals who have a developmental disability(Form 4588 is required). If category 2 or 6 are checked above,enter veteran's service dates. Veteran's Service Dales Beginning and Ending (Menne (nail man (Mean --. (CM Clean 1 Do you currently awn this residence/ YES ❑NO 2 Do you current r��y occupy this residence? - u,{yES 0 N 3 If you or your spouse are currently residing in a nursing home,please answer these questions: •What date rid you enter the nursing home? f / (Mo/DayNf)-or spouse__/ / (Mo/Day/Yr) •Have the household furnishings been removed from your residence/ ❑YES •Is the residence currently occupied,leased,or rented by another person? ❑YES If Yes,who is residing in the residence? 4 Is this homestead owned by a trust? OYES [L_]-a9 •If Yes,are you residing at this homestead as abenefidary under the trust instrument? ❑YES [yJA0O 5 If you received a homestead exemption last year,Is the preprinted Mimi-natal on the form complete and correct(names, Social Security numbers,birth dates,'ling status,exemption category,other owner-occupants,etc)/ S ❑NO •If No,please indicate the correct information in the appropdale area Other Owners Who Occupy The Residence(Attach list If necessary.) •Nebraska Schedule I—Income Statement must be tiled for each owner-occupant(DO NOT repeat eppllcent and spouse.) Name I Relationship to Aeollcant! Date of Birth MMe/Day/Yr)I Social Security Number / Under penalties of law,I declare Thal I have aamined his bon and that it 1%to are besi of my knowkidge and bete(true and cannel.I also declare that I am entitled to the Nebraska homestead exemption and have not applied for a homestead exemplon elsewhere in the stale. I am a citizen of the United States. ❑I am qualified alien under the Feder\ )knmi, atlon end Nationalit Act,My immigration status and alien number are sign as 4 tows• — and I agree d-a copy of my US=documentation upon request. a ■ La it 1/7/ i8 €--38� a.aa here Sig(a -of Apptcan le Telephone Number FOR COUNTY ASSESSOR'S USE ONLY Parcel of Location ID hammer Tax Dislrbi Number CLerenl AssessedValue of the Homestead Ropperty 400201372 325 ❑Approved Comments: ❑Disapproved Date Received by Calmly Assessor "Signahpe of County Assessor Dale Nebraska Departmen cr Rnave Auwnreb by Neb.Pee Sal 55773510-14 and 773528 Flle with your county assessor atter February 1 and by June 30. roes No 98,295.2009 Rev 1-2015 Mimed wit,soy ink onreoyohd papa Retain a copy for your records. Supersedes 96-295-2009 Re.1•2017