Homeowner's Questionnaire

Cedar Rapids City - Assessor's Office

If an inspection is not possible, please complete this form and submit to the Cedar Rapids City Assessor's Office. It will assist us in verifying the information for your property. Thank you for your cooperation.

Parcel Number:	11303-51007-00000
Address:	5516 WEST MUSTANG RD NE CEDAR RAPIDS, IA 52411-0000
Class:	RESIDENTIAL
Neighborhood:	NE 169
Deedholder:	POOLE JOINT REV TRUST
Contract:
Mailing Address:	% MARK R & LANA M POOLE CO TRUSTEES 5516 W MUSTANG RD CEDAR RAPIDS, IA 52411-8232

PROPERTY LISTING

Is listing correct? If No, explain:

Exterior Walls:

Vinyl

Yes *

No *

Response required.

Total Living Area (SF):

Above Ground

2,798

Yes *

No *

Response required.

Total Bsmt Finish (SF):

1,043

Yes *

No *

Response required.

Please describe basement finish:

Response required.

Flooring:

Carp / Vinyl / Hdwd

Yes *

No *

Response required.

Total # Rooms:

Yes *

No *

Response required.

Total # Bedrooms:

Yes *

No *

Response required.

Plumbing List:

Style	Count
Standard Bath - 3 Fixt	1
Toilet Room (1/2 Bath)	1
Lavatory	2
Sink	1
Wet Bar	1
Whirlpool Bath - 3 Fixt	1
Prefab/Mtl St Sh Bath	1
Prefab/Mtl Stall Shower	1

Yes *

No *

Response required.

Central Air Conditioning:

Yes

Yes *

No *

Response required.

Heat:

FHA - Gas

Yes *

No *

Response required.

Fireplace:

Yes *

No *

Response required.

Garage:

Yes *

No *

Response required.

If interior of garage is finished, please describe:

Response required.

GENERAL QUESTIONS

Overall condition of the property, in your opinion:

Excellent *

Above Normal *

Normal *

Below Normal *

Poor *

Condition Comments:

Is your property sketch below correct? Review Sketch Abbreviations

Yes *

No *

Sketch Explain:

Response required.

Are there any other changes to the property? (ie: remodel, renovation, new buildings,
new additions, new construction, demolition, removal, other)

Owner's Name:

Response required.

Date:

Enter today's date.

Response required.

Daytime Telephone Type:

Work *

Home *

Cell *

Telephone Number:

Format: (321) 456-7890

Response required.

Email Address:

Response required.

DECLARATION AND SIGNATURE

Iowa Code – 441.19 Owner to assist – provisions for assessment:

The assessor shall list every property in the assessor's county or city as the case may be and assess all the property in the county or city, except property exempted or otherwise assessed. A person who refuses to assist in making out a list of the person's property, or of any property which the person is by law required to assist in listing, is guilty of a simple misdemeanor.

I, the undersigned, declare under penalties of perjury or false certificate, that I have examined this application, and, to the best of my knowledge and belief, it is true, correct, and complete.

Please enter signature below.

Signature:

Please sign your name with your finger or your mouse.

Signature is required.