Form Ptr-2b - Verification Of Mobile Home Park Site Fees

Form PTR-2B

Mobile Home Owners

Verification of 2016 Mobile Home Park Site Fees

(Applicant completes Parts I and III. Mobile home park owner or manager completes Part II.

Use blue or black ink. See instructions for completion on back.)

Part I — To Be Completed by Applicant

Social Security #

–

Spouse’s/CU Partner’s Social Security #

–

Name

______________________________________________________________________________________

Last Name, First Name, and Initial (Joint filers, enter first name and initial of each - Enter spouse’s/CU partner’s last name ONLY if different)

Address ______________________________________________________________________________________

Street

City

State

Zip Code

Mobile Home Park Site # ___________________________________________

A. Did someone who was not your spouse/CU partner occupy your mobile home and share

Yes

site fees with you? If you (and your spouse/CU partner) were the sole occupant(s), check “No.”

B. Indicate the share (percentage) of the site fees that you (and your spouse/CU partner)

paid. If you (and your spouse/CU partner) were the sole occupant(s), enter 100%.

Part II — To Be Completed by Mobile Home Park Owner or Manager

2016 Site Fees

(Do not include municipal service fees or other charges)

1. Total site fees due for calendar year 2016 under agreement with mobile home park . . . . . . . . . . . . . .$ __________

2. Total site fees paid by resident(s) for calendar year 2016 only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ __________

If Line 2 is less than Line 1, do not complete the certification. The applicant is not eligible for a reimbursement.

Under the penalties of perjury, I certify that I am the owner or manager of____________________________________,

where the above mobile home site is located. I further certify that the above-stated amounts of site fees due were paid

for calendar year 2016 and are true and accurate to the best of my knowledge.

__________________________________________

(Name)

(Date)

__________________________________________

(Title)

(Phone)

Part III — To Be Completed by Applicant

(AFTER Part II has been completed by mobile home park owner or manager)

3. Total site fees paid by all residents living at this address.

(Enter amount from Part II, Line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ __________

4. Share (percentage) of site fees that you (and your spouse/CU partner) paid.

(Enter percentage from Part I, Line B as a decimal. For example, if the share is 50%, enter 0.50.

If 100%, enter 1.00) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .× __________

5. Total site fees paid by you (and your spouse/CU partner) (Line 3 × Line 4) . . . . . . . . . . . . . . . . . . . . .$ __________

6. Total property taxes paid by you (and your spouse/CU partner)

(Line 5 × 0.18) Enter this amount on Line 9, Form PTR-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $__________

(If you complete this form, be sure to enclose it with your Form PTR-2 application.)