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Form PTR-2B
Mobile Home Owners
Verificationof2019MobileHomeParkSiteFees
(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
LastName,FirstName,andInitial(Jointfilersenterfirstnameandinitialofeach-Enterspouse’s/CU partner’s last name ONLY if different)

Address
Street City ZIPCode

Mobile Home Park Site #

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)werethesoleoccupant(s),check Yes 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

2019 Site Fees
(Do not include municipal service fees or other charges)
1. Total site fees due for Calendar Year 2019 under agreement with mobile home park ................$

2. Total site fees paid by resident(s) for Calendar Year 2019 only ..................................................$
Ifline2islessthanline1,donotcompletethecertification.Theapplicantisnoteligibleforareimbursement.

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 Year 2019 and are true and accurate to the best of my knowledge.

(Name) (Date)

(Title) (Phone)

Part III — To Be Completed by Applicant (AFTER Part II has been completed by mobile home park owner or manager)
3. Total site fees paid by all residents living at this address.
(EnteramountfromPartII,line2) ........................................................................................................$

4. Share (percentage) of site fees that you (and your spouse/CU partner) paid.
(EnterpercentagefromPartI,lineBasadecimal.Forexample,iftheshareis50%,enter0.50.
If 100%, enter 1.00) .............................................................................................................................. 

5. Total site fees paid by you (and your spouse/CU partner) (line 3 line 4) ..........................................$

6. Total property taxes paid by you (and your spouse/CU partner)
(Line 5 0.18) Enter this amount on line 10, Form PTR-2 ............................................................$

(If you complete this form, be sure to enclose it with your Form PTR-2 application.)

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Form PTR-2B – Instructions

Part I – To Be Completed by Applicant
Social Security Number. If your marital/civil union status Mobile Home Park Site Number.Enterthemobilehome
as of December 31, 2019, was single, you must enter your park site number of the principal residence for which you are
Social Security number in the space provided on Form claiming the reimbursement in the space provided.
PTR-2B. If your status as of December 31, 2019, was mar-
ried/CU couple, you must report both applicants’ numbers in A. Multiple Occupants.Check“Yes”onlyifyouoccupied
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 part-
“Single”forpurposesofthePropertyTaxReimbursement. ner)werethesoleoccupant(s),check“No.”
You should enter only your Social Security number on Entertheshare(per-
B. Percentage of Site Fees Paid.
Form PTR-2B. centage) of the site fees that you (and your spouse/civil
Name and Address. Print or type your name (last name union partner) paid. For example, if you and your sister
first)andcompleteaddressofthepropertyforwhichyouare lived in your mobile home and you both paid one-half
claiming the reimbursement in the spaces provided. Also of the site fees, you must enter 50% as your share. If
includeyourspouse’s/CUpartner’snameiffilingjointly. you (and your spouse/CU partner) were the sole occu-
pant(s), enter 100%.

Part II – To Be Completed by Mobile Home Park Owner or Manager
EntertheappropriateamountsforCalendar Year2019 Compare lines 1 and 2.
as follows:
• Ifline2isequaltoline1,completethecertification
Line 1. Entertheamountofsitefeesdueunderthe mobile portion of Form PTR-2B.
home park agreement entered into with the resident(s).
• If line 2 is less than line 1, do not complete the
Line 2.Enterthetotalamountofmobilehomeparksitefees certificationportionofFormPTR-2B. The applicant is
paidby,oronbehalfof,theresident(s).Enteronly amounts not eligible for a Property Tax Reimbursement.
actually due and paid for the calendar year.
Certification.Completethecertificationportionof
Form PTR-2B.

Part III – To Be Completed by Applicant
Line 3 – Total Site Fees Paid. Enterthetotalsitefeespaid Line 5 – Total Site Fees Paid by Applicant. Multiply the
for the calendar year by all residents who lived in the mobile amount on line 3 by the decimal on line 4.
homeforwhichyouareclaiminga reimbursement.(Enter Line 6 – Total Property Taxes Paid by Applicant. Multiply
amount from Part II, line 2.) the amount of site fees on line 5 by 18% (0.18) and enter
Line 4 – Percentage of Site Fees Paid. Enteryourshare the result in the box at line 6.
(percentage) of site fees paid from Part I, line B for the
calendaryear.Enterthisnumberasadecimal.Forexample,
if you lived in your mobile home with your sister and you
both paid 50% of the site fees, enter 0.50 on line 4. If you
(and your spouse/CU partner) were the sole occu pant(s),
enter 1.00.

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