DTE Form 49 (Revised 11/97) RC 4503.0611 Application No. DATE RECEIVED APPLICATION FOR TAX REFUND OR WAIVER FOR DESTROYED OR DAMAGED MANUFACTURED HOMES ANSWER ALL QUESTIONS AND TYPE OR PRINT ALL INFORMATION READ INSTRUCTIONS ON BACK BEFORE COMPLETING FORM Please return to: GEAUGA COUNTY AUDITOR Courthouse Annex 231 Main Street Chardon, OH 44024-1293 1. OWNER'S NAME 2. OWNER'S ADDRESS CITY/STATE 3. OWNER'S TELEPHONE NUMBER ( ) ZIP 4. REGISTRATION NUMBER OF DAMAGED HOME 5. ADDRESS OF DAMAGED HOME CITY/STATE 6. COUNTY WHERE LOCATED 7. DATE DAMAGE OCCURRED 8. CAUSE OF DAMAGE 9. DESCRIPTION OF DAMAGE ZIP 10. ESTIMATED DOLLAR AMOUNT OF DAMAGE $ 11. IF PROPERTY INSURED, AMOUNT OF INSURANCE RECEIVED $ I declare under penalties of perjury that this application has been examined by me and, to the best of my knowledge and belief, it is true, correct and complete. OWNER Signature Sworn to and signed in my presence, this __________ day of _________________, _____. DATE Notary Public American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING FORM FILING DEADLINES AND SCHEDULE OF DEDUCTIONS: An application for refund or waiver of the current year's taxes must be filed no later than the 31st day of January following the year in which the destruction or damage occurred. Any tax refund or waiver approved will affect the tax bills for the year in which the damage or destruction occurred. The amount of the tax refund or waiver equals a percentage of the tax on the reduction in the value of the home caused by the damage or destruction. That percentage is determined by the calendar half in which the damage occurred. The filing deadline and percentage deduction in taxes allowed for each calendar half are shown below. CALENDAR HALF IN WHICH HOME WAS DAMAGED JANUARY - JUNE JULY - DECEMBER LINE INSTRUCTIONS: LINES 1, 2 and 3: LINE 4: LINE 5: LINE 6: LINE 7: LINE 8: LINE 9: LINE 10: LINE 11: Enter owner's full name, mailing address, and daytime phone number. Enter registration number(s) of damaged home. This number is shown on your tax bill. Enter the full address of the damaged home. Enter name of county where damaged home is or was located. Enter date the damage or destruction occurred. Explain cause of damage: fire, flood, intentional demolition, etc. Describe the damage to the home, attach additional pages if necessary. Enter your best estimate of the reduction in the home's value caused by the damage. If home is insured, show the amount the insurance company paid or will pay, if available. PERCENTAGE DEDUCTION ALLOWED 100% 50% APPLICATION DEADLINE JANUARY 31 JANUARY 31 OWNER'S SIGNATURE: Sign and date the application at the bottom and have your signature notarized. If the owner's signature is not notarized, the section below must be completed and notarized. AFFIDAVIT OF TWO DISINTERESTED PERSONS If the owner's signature is notarized on the front of this application, this affidavit is not necessary. and being duly sworn, say that they are residents of the municipal corporation or township in which the above home is or was situated, that neither of them has any interest therein, and that home was destroyed on the date show above. Signed Sworn to and signed in my presence, this _______ day of _________________, _______. DTE Form 49 (Revised 11/97) Notary Public 10/02 American LegalNet, Inc. www.FormsWorkFlow.com