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Form PTR-1B Mobile Home Owners
Verification of 2019 and 2020 Mobile Home Park Site Fees
(Applicant completes Parts I and III. Mobile home park owner or manager completes Part II.
Use blue or black ink. See instructions for completion on back.)

Part I — To Be Completed by Applicant
Social Security # – – Spouse’s/CU Partner’s Social Security # – –
Name
Last Name, First Name, and Middle Initial (Follow with first name and initial of spouse/CU partner if filing jointly. Only enter spouse/CU partner’s last name if different.)
Address
Street City State ZIP Code

Mobile Home Park Site #
2019 2020
A. Did someone who was not your spouse/CU partner occupy your mobile
home and share site fees with you? If you (and your spouse/CU partner) Yes No Yes No
were the sole occupant(s), check “No.”
B. Indicate the share (percentage) of the site fees that you and your
spouse/CU partner paid. If you (and your spouse/CU partner)
were the sole occupant(s), enter 100%. % %

Part II — To Be Completed by Mobile Home Park Owner or Manager
Column A — 2019 Site Fees Column B — 2020 Site Fees
(Do not include municipal service fees or other charges) (Do not include municipal service fees or other charges)
1. Total site fees due for Calendar Year 2019 1. Total site fees due for Calendar Year 2020
under agreement with mobile home park. ....... $ under agreement with mobile home park. ..........$

2. Total site fees paid by resident(s) for 2. Total site fees paid by resident(s) for
Calendar Year 2019 only. ................................ $ Calendar Year 2020 only. ...................................$
If line 2 is less than line 1, do not complete the certifica- If line 2 is less than line 1, do not complete the certification.
tion. The applicant is not eligible for a reimbursement. The applicant is not eligible for a reimbursement.

Under the penalties of perjury, 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 were paid
for Calendar Years 2019 and 2020 and are true and accurate to the best of my knowledge.

(Name) (Title) (Date) (Phone)

Part III — To Be Completed by Applicant (AFTER Part II has been completed by mobile home park owner or manager)
Column A — 2019 Column B — 2020
3. Total site fees paid by all residents living at this 3. Total site fees paid by all residents living at this
address. (Enter amount from Part II, line 2, address. (Enter amount from Part II, line 2,
column A) .......................................................... $ __________ column B).......................................................... $ __________
4. Share (percentage) of site fees that you (and 4. Share (percentage) of site fees that you (and
your spouse/CU partner) paid in 2019. (Enter your spouse/CU partner) paid in 2020. (Enter
percentage from Part I, line B as a decimal. percentage from Part I, line B as a decimal.
For example, if the share is 50%, enter 0.50. For example, if the share is 50%, enter 0.50.
If 100%, enter 1.00) .......................................... __________ If 100%, enter 1.00) .......................................... __________
5. Total site fees paid by you (and your spouse/ 5. Total site fees paid by you (and your spouse/
CU partner) (line 3  line 4) .............................. $ __________ CU partner) (line 3  line 4) .............................. $ __________
6. Total property taxes paid by you (and your 6. Total property taxes paid by you (and your
spouse/CU partner) (line 5  0.18). Enter spouse/CU partner) (line 5  0.18). Enter
this amount on line 14, Form PTR-1 ...... $ __________ this amount on line 13, Form PTR-1 ...... $ __________

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

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Form PTR-1B – Instructions

Part I – To Be Completed by Applicant
Social Security Number. If your marital/civil union status Mobile Home Park Site Number. Enter the mobile home
as of De cember 31, 2020, was single, you must enter your park site number of the principal residence (main home)
Social Security number in the space provided on Form for which you are claiming the reimbursement in the space
PTR-1B. If your status as of December 31, 2020, was mar- provided.
ried/CU couple, you must report both applicants’ numbers in Check “Yes” only if you occupied
A. Multiple Occupants.
the order in which the names are listed on the application. your mobile home with someone who was not your
If you were married or in a civil union but living apart from spouse/CU partner and shared mobile home park site
your spouse/CU partner, and you did not have access to fees with them. For example, you lived in your mobile
or receive support from their income, you are considered home with your sister. If you (and your spouse/CU
“Single” for purposes of the Property Tax Reimbursement. partner) were the sole occupant(s), check “No.”
You should enter only your Social Security number on Form
PTR-1B. B. Percentage of Site Fees Paid. Enter the share (per-
centage) of the site fees that you (and your spouse/CU
Name and Address. Print or type your name (last name partner) paid. For example, if you and your sister lived
first) and complete address of the property for which you in your mobile home and you both paid one-half of the
are claiming the reimbursement in the spaces provided. site fees, you must enter 50% as your share. If you (and
Also include your spouse’s/CU partner’s name if filing jointly. your spouse/CU partner) were the sole occupant(s), en-
ter 100%.

Part II – To Be Completed by Mobile Home Park Owner or Manager

Enter the appropriate amounts for Calendar Years Compare lines 1 and 2 for each calendar year.
2019 and 2020 as follows:
• If line 2 is equal to line 1 for both years, complete the
Line 1. Enter the amount of site fees due under the mobile certification portion of Form PTR-1B.
home park agreement entered into with the resident(s).
•
Line 2. Enter the total amount of mobile home park site fees If line 2 is less than line 1 for either or both years,
paid by, or on behalf of, the resident(s). Enter only amounts do not complete the certification portion of Form
actually due and paid for each calendar year. PTR-1B. The applicant is not eligible for a Property Tax
Reimbursement.

Certification. Complete the certification portion of Form
PTR-1B.

Part III – To Be Completed by Applicant

Line 3 – Total Site Fees Paid. Enter the total site fees you and your spouse/CU partner were the sole occu pant(s),
paid for each calendar year by all residents who lived in the enter 1.00.
mobile home for which you are claiming a reimbursement.
(Enter amount from Part II, line 2.) Line 5 – Total Site Fees Paid by Applicant. Multiply the
amount on line 3 by the decimal on line 4.
Line 4 – Percentage of Site Fees Paid. Enter your share
(percentage) of site fees paid from Part I, line B for each Line 6 – Total Property Taxes Paid by Applicant. Multiply
calendar year. Enter this number as a decimal. For exam- the amount of site fees on line 5 by 18% (0.18) and enter
ple, if you lived in your mobile home with your sister and the result in the box at line 6.
you both paid 50% of the site fees, enter 0.50 on line 4. If

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