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Form Ptr-1b - Verification Of 1998 And 1999 Mobile Home Park Site Fees For Property Tax Reimbursement Applicants

FORM PTR-1B

Mobile Home Owners

Verification of 1998 and 1999

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 #

_________________________________________________________

1998 Site Fees

1999 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 1998 and 1999 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)

Form Ptr-1b - Verification Of 1998 And 1999 Mobile Home Park Site Fees For Property Tax Reimbursement Applicants