Homestead_Dyer (5)"'" CLAIM FOR HOMESTEAD PROPERTY TAX FORM YEna
i_ STANDARD / SUPPLEMENTAL DEDUCTION HCto
State Fomi 5973 (R72 / 6-09) ,
',„ � Prasaibed 6y the Department af Laal Govemmem Fnarce y--� ����
9_.+,
INSTRUCT70NS: See raverse skle for fif"vu,7 instnictbns. � 8
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I(V✓e) certify Nat I(we) oxupied as my (our) pri�pal
place ot residence or a are) buying the followin describ d al property for which a Homestead Prope�� nd.jrdpeduclion is hereby daimed
under conVaG on Ue d e this appiicalion is filed, (date of filrng): 0�� �� jj.
❑ 1(we) own ❑ Am (are) buying under recorded contract GIBSON COUNTY AUDITOR .
❑ Am (are) enUtled to ocwpy as a tenant-stockholder of a cooperaWe housing corporetion
� Have a beneficial interest in the Wst or the right m occupy the property under the tertns of a qualified personal residence Wst
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Name M daimant (legel na
Sodal Smrtiry�{
�
Nama of dauria(rt's spouse (legal name)
Sodal Seamry m�mbPi ot tlaimant's spouse (lasf five tlipi(s) Drivers ficeM1Se / Identifiption I ONer number Iswirg oxo
ot daimam's spouse (les! (rve dqiLS)
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11 Aryvig on oontrarl, Fee Simple ovmefs rume
Rttofdets al&s whe2 mnVad is reco�deE ' . Record numbu Page
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Counry Twnship Tamg disbict ( t r /n�
�
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i wooem ❑,w���i a�sm �a�e r� uc c-,.,-n
If any poMion of the resMenfial sWCWre or Ne W�W nol ezceedi� are (7 ) atte Iha[ Mmediatety wrtou s Ihat strucWre k used to produce imm�a, Oesrnbe iha use aM portron
� of Ne PmPenY wT¢etl lo W�uce income.
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Counry Tv,mship Caunry Township
I hereby certify the above statements are we, oortea and complete. � "� / �
MEress (number an0 stree4 aN. sfate. antl IPmOe)
'� 3 _ �Sn E. � ►�c�.� i,.� �t7�Z ti
.- .
, . .. . ,
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LanA nol e:ceeding 1(on¢) acre immediatety r y`�� *�. -.'�F > "�
aurtoundin resitlential im rovemen5. (�) ��'r"'�' ���� '�-?'
�Y:a�+ '4 _.1 YZ_"TIL �..X�Sr'�
° v-� y�.
ONer land ' (2) y. �s'<.. a�
�:'���. �
7atal land Qine 1 plus line � (3)
Dweliing (4) . '`i$'��'��wakT��-'£.. ����
ResltlenUal impravements or Mnually =�'e+ �i=� `+ � ° '�"�-��t=`�-
Assessed Mobik I Manufacwretl Hortre Garzge �5) '� ,�."�Trr��r,Y.�ryn•G�-�.'v
4':iY-i r'y�;r�.,.w'�'nr�.'�`54%rh`''Y�;"a,.,°�`.
Other impmvemertls (6) �y, .aM-'k��'�Y
SF."�_.����,,:r. J`ay'.
Total Improvemen6 (llne I fhroughline � (7)
Total value (line 3 pl�c line � (8)
I hereby certify the above is true, cortect, S�`�ti'� °f ��55Of ��"� ("1O^N, �y ��%
and complete.
veiyin9 aGbn - SignaWre otAudtor . Dete signetl (month. OaY. Y��
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20 _ pay 20 _ Lesser of 60% of the assessed value of ihe homestead or 845.000
rMM�i(4varW'ug eny ofAerProvision. Ifie swn W the deducfions provitletl in IC bf. f-72 m a mo6ile Mme Ihat /s $
not essessetl as real properry or �o a manuladured home Nat is not assessed as reel pmperry rrey no1 erceed
one�haH(iR� sussed velue a/1he bde e w manu7arturetl horne.
of DatO Sign�d rtryrrth�y„year�, �
� C/�lr �