Form Hs-9 - Support Of Demand For Homestead Refund Kansas

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Form
KANSAS
HS-9
SUPPORT OF DEMAND FOR HOMESTEAD REFUND
(Rev. 8/00)
Name of Homestead Refund Claimant
Social Security Number
INSTRUCTIONS: Use this form if a claimant is incapable of signing the Homestead Claim, and no guardian or conservator
has been appointed. If a guardian or conservator has been appointed, do not use this form. Enclose instead a copy of
your appointing documentation (guardian, conservator, power of attorney) with Form K-40H.
I, the undersigned, of lawful age depose that I am well acquainted with the facts concerning the Homestead Claim for
the year
of the above-named claimant, that a Homestead Refund is rightfully due, and
that the marked set of circumstances describe the situation of the claimant:
The claimant is incompetent, there has been no judicial appointment of a guardian or conservator, and the individual
is a spouse, or adult child of the incompetent and should rightfully receive the Homestead Refund.
The claimant is blind, ill, or incapable of signing the Homestead Claim.
Other reason. (Be specific and print clearly)
That if the State of Kansas; Secretary of Revenue; Director of Accounts and Reports; State Treasurer; or, any of their
officers, agents or employees, certify, prepare, sign or deliver to myself, the Kansas Homestead Refund and, any demand
or claim is made upon the State of Kansas; Secretary of Revenue; Director of Accounts and Reports; State Treasurer; or,
their officers, agents or employees, by any person whatsoever, I shall at all times save the State of Kansas; Secretary of
Revenue; Director of Accounts and Reports; State Treasurer; or, their officers, agents and employees, harmless, free and
clear of all costs, expenses or damages occasioned by the certification, preparation, signing or delivery of the Homestead
Refund of the above-named claimant to myself.
Under the penalties of perjury, I declare that the information I have furnished above, to the best of my knowledge,
is true, correct and complete.
Name (Print or Type)
Signature
Address
City, State and Zip Code
Date:

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