Form Ptr-1b - Mobile Home Owners Verification Of 1999 And 2000 Mobile Home Park Site Fees For Property Tax Reimbursement Applicants

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FORM PTR-1B
Mobile Home Owners
Verification of 1999 and 2000
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 #
_________________________________________________________
1999 Site Fees
2000 Site Fees
Total Amount Due
$ ___________
Total Amount Due
$ ___________
Total Amount Paid
$ ___________
Total Amount Paid
$ ___________
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 1999 and 2000 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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