HomeMy WebLinkAboutJune 28, 2010 MANUFACTURED & MOBILE HOME STATEMENT OF RECEIVED
MONTHLY MUNICIPAL PERMIT FEE
INSTRUCTIONS JUN 3 0 1010
MANUFACTURED & MOBILE HOME COMMUNITY OPERATOR (orowner of land if manufactured or mobile home su b e ct
to tee is located outside of community): Complete Section A with manufactured or mobile home owner. Submit in duplicate
to your local Assessor within 5 days of the arrival of each unit.
ASSESSOR: Complete Section B. Determine the fair market value of the manufactured or mobile home. (Use PA-117,
Manufactured & Mobile Home Valuation Worksheet). NOTE: Exempt fumishings must be subtracted from the fair market
value if included in that figure. Submit form to local Clerk for computation of municipal permit fee
CLERK: Complete Section C.
SECTION A
TAXATION DISTRICT SCHOOL DISTRICT COUNTY �f. y�� NAME OF MANUFACTURED OR MOBILE HOME OWNER
TO BE NAME OF COMMUNITY —
ADDRESS OFM NUFACTURED OR MOBILE HOME
COMPLETED -6 -4 -1 - --.E5±
COMMUNI ADDRESS ARRIVAL DATE OWNER PERMANENT ADDRESS n_.,
s-
BY ��
COMMUNITY ,.-7 �� -, ,
MANUFACTURED OR MOBILE HOME DESCRIPTION f
OPERATOR MANUFACTURER'S NAME
MODEL OR POPULAR NAME SERIAL NUMBER
AND
PROF MANUFACTURE } PURCHASE YEAR PURCHASE PRICE ------- — WRHD
MANUFAC- I PURCHASED AS _.. - - E - - PURC -- ASE ._ •
TURED OR • • - - _ DNEW ❑usEo
DO LICENSE NO.(IFAPPLICABLE);WIDTH LENGTH WEIGHT COLOR INO OFAxLES
MOBILE I BILL OF SALE )TITLE I
NO OF ROOM - -•-
HOME GOES T HE UNIT HAVE ..1 ..._.._ . __._. .....___... -...
BATHS BORMS 1 0 SKIRTING
U _.
OWNER " " —' 0 FIREPLACE PORCH — _- __ -._.. _, Sr
TOTAL ROOMS I 0 AIR CONDITIONING 0 WASHER [7 PATIO
DISHWASHER -- " - " "' - - Sr
C7
.. ..__... _.._.._. ...... ._......... . . 1_ _____ .._..__._._.._..__.___ U DRYER Li CARPORT
sr
PLEASE SI TU RE OF UNIT OW
I t j DATE
SIGN HERE f�
t ...1" / ■ ' (0 as/It
SECTION B - VALUATION
DATE VIEWED OR INSPECTED
ASSESSOR 1 . Total Fair Market Value $
2. Exempt Furnishings - $ _!_•— _
3. NET FAIR MARKET VALUE SIGNATURE OF ASSESSOR
(Subtract line 2 from line 1)
_ SECTION C – COMPUTATION OF MUNICIPAL PERMIT FEE
4. Net Fair Market Value (from line 3 above) $ The first monthly fee
5. % Level of Local Assessment covers the month of
X
(established for preceding Jan. 1 assessment) - - -- `" ---
6. Value for Fee Computation (multiply line 4 by line 5) .... $
(Enter month)
7. Net Tax Rate (after state tax credit) and is due on or
(established for preceding January 1 assessment) X before the tOth day of
8. Annual Fee (multiply line 6 by line 7) ~ —
9. Gross Monthly Fee (divide line 8 by 12 months) $ (Enter the following month)
10. Lottery Credit (if applicable) — - The monthly fee is
- $_._ — _____ _ ___ _ due on or before the
11. Net Monthly Fee (subtract line 10 from line 9) $ — _ 10th day of each
PA-1lD (R. 10 -07) -- month thereafter
Wisconsin Deparlmenl of Rerenae
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