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Form PTR-1B

Mobile Home Owners

Verification of 2001 and 2002 Mobile Home Park Site Fees

(see instructions on back)

Part I — To Be Completed By Applicant

(Part II to be completed by mobile home park owner or manager)

–

Socia l Security Num ber

Spouse’s Socia l Security N um ber

Nam e

Last Name, First N ame and Initial (Joint filers enter first name and initial of each - Enter s pouse’s last nam e O NLY if different)

Address

Street

City

State

Zip Code

M obile H om e Park Site #

2001

2002

A. Did you occup y your m obile hom e w ith som eone other th an your spouse and share

Yes

N o

Yes

N o

site fees with th em ? If you (and your spo use) were the sole occupan t, check “No.”

B. If yes, indicate the share (percentage) of the site fees that you (a nd your spouse) paid.

If yo u (an d your sp ouse) were th e sole occupa nt, enter 100%

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

Column A — 2001 Site Fees

Column B — 2002 Site Fees

1. Total site fees due under agreement

with mobile home park ........................... $

2. Total site fees paid by resident(s).......... $

2. Total site fees paid by resident(s) .......... $

I certify that I am the owner or manager of _______________________________________ , where the above mobile home

is located. I further certify that the above stated amounts of site fees due and paid for calendar years 2001 and 2002 are true

and accurate to the best of my knowledge.

(Name)

(Title)

(Phone)

Part III — To Be Completed By Applicant

Column A — 2001

Column B — 2002

3. Total number of residents (including applicant)

who shared site fees. (Spouses filing joint

application count as one (1) occupant) ________

4. Total site fees paid by all residents living at this

address. (Enter amount from Part II, Line 2,

Column A).........................................................

Column B).........................................................

5. Share (percentage) of site fees that you (and

your spouse) paid in 2001 from Part I, Line B.

your spouse) paid in 2002 from Part I, Line B.

(Enter this number as a decimal. For example,

if the share is 50%, enter 0.50. If you were the

sole occupant, enter 1.00) ................................

6. Total site fees paid by you (and your spouse)

(Line 4 × Line 5). Enter in space for site fees

at Line 14, Form PTR-1 ..................................

$ _________

at Line 13, Form PTR-1 ..................................

$ _________

(If you complete this form, be sure to enclose it with your Form PTR-1 application)

Form Ptr-1b - Mobile Home Owners Verification Of 2001 And 2002 Mobile Home Park Site Fees

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