Form Ptr-1b - Verification Of 2000 And 2001 Mobile Home Park Site Fees For Property Tax Reimbursement Applicants

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FORM PTR-1B
Mobile Home Owners
Verification of 2000 and 2001
Mobile Home Park Site Fees for
Property Tax Reimbursement Applicants
Social Security Number
Spouse’s Social Security Number
First Name
__________________________
Last Name _______________________________
Address
_____________________________________________________________________
_____________________________________________________________________
Mobile Home Park Site # __________________________________________________________
2000 Site Fees
2001 Site Fees
1. Total Amount Paid
$ _____________
1. Total Amount Paid
$ _____________
2. Total Amount Due
$ _____________
2. Total Amount Due
$ _____________
(Enter in space for mobile home
(Enter in space for mobile home
park site fees at Line 11, Form PTR-1)
park site fees at Line 10, Form PTR-1)
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 and paid for calendar years 2000 and 2001 are true and
accurate to the best of my knowledge.
__________________________________________
(Name)
__________________________________________
(Title)
(If you complete this form, be sure to enclose it with your Form PTR-1 application)

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