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HC 201 (1/93) APPLteA'fiON FOR HOMESTEAD <br />(OFFICE USE ON LY) (Read the back of this application [HC 201 BJ before filling in information below.) , l I - <br />MUNIC# PIO# <br />J -1. 3 -II 7 -.23 <br />APPLICANT DAT A (Please Print) <br />LAST NAME <br />ADDRESS <br />DATE OF DEED <br />3 o-- <br />i) 5 <br />OWNER(S) -NON-OCCUPYING <br />NAME <br />ARE YOU RELATED TO THE OWNERS? I RELATIONSHIP <br />□ NO □ YES <br />□ OWNER □ RELATIVE CRVFILED □ MID z_ OCCUPIED OCCUPIED YEAR <br />FULL YEAR □YEAR <br />MIDDLE INITIAL <br />PURCHASE PRICE <br />rv(WARRANTY □ CONTRACT □ OTHER <br />~DEED DEED <br />PREVIOUS ADDRESS SOCIAL SECURITY# <br />ADDRESS SOCIAL SECURITY# <br />. <br />RELATIVE -OCCUPYING PROPERTY AS PRIMARY RESIDENCE <br />NAME RELATIONSHIP TO OWNER SOCIAL SECURITY# <br />~ <br />You can have only one homestead. By signing this application, you are declaring that the property described above is the <br />primary residence of the owner(s) of the property or of a qualified relative of the owner(s) and that you have received, read and <br />understand form HC 201 B (RE:produc&d on the back of tr1is application). <br />NOTE PENAL TY: Whoever, in making any statement, oral or written, which :s required by law to be made as a basis for <br />imposing, reducing or abating any tax or assessment, intentionally makes 2.ny statement as to any material matter which <br />he/she knows to be false, may be sentenced, unless otherwise provided by law, to imprisonment for not more than one year or <br />to a fine of not more than $3,000.00, or both. (Minn. Stat. 609.41) <br />~ The law requires that a "Certificate of Real Estate Value" must be filed before a homestead can be granted. (Minn. Stat. <br />272.115) <br />I have read and understand the qualifications reproduced on the back of this aoolication (HC 201 B). I declare to the best of my <br />knowledge the information contained on this application (HC 201) is correct. <br />OFFICE USE ONLY <br />TAKE!NBY: .k <br />• <br />WHITE -ASSESSOR'S OFFICE <br />SIGNATURE OF OWNER/RELATIVE IF APPLICABLE <br />. <br />CANARY -MUNICIPALITY PINK -APPLICANT