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e% �� °� CLAIM FOR HOMESTEAD PROPERTY TAX ' ` vEAR
�'�� CREDIT/STANDARD DEDUCTION
�;;�� State Form 5473 (fl2 / 5�92) _ . ,
m1� . � . .. . � . - "
INSTRUCTIONS: See reverse side for7iling inshuctions. - APR 2 6 �99?
- - � � � - � CERTIFICATION STATEMENT . . .
'^v_) `f' ��Q� certify that on the tst d�ylDUU8rbF1!19
�i) occupied as our principal place of residence the following described real property tor which a Homestead Property Tax Credit is hereby claimed:
I❑ I(We) owned .❑ Are buying under contract , ,
❑ Have a beneficial interest in the entity thai is liable for the property taxes on the property and ihat owns the property or is buying under a contraci.
- CONTRACT RECORDED - �
If buying on con(rac6 Fee Simple owner'S name � . . -
Recordefs o(fice where comract is recorded fiecord number Page
Counry
�-O(A4�'-0� �- �-
I( any potlion of the resitlential stmcwre or the land
of the pmpeny utilizetl m protluce income.
PROPERTY DESCHIPTION
Ta�cing districl (ciry, town. lownship)
/i .
>� q-a=- ro a a_e_ . . .
one (1) aae that immetliatety surrountls that strucNre is used to produce income, descnbe the use and portion
ASSESSOR USE ONLY TRUETAX ASSESSED HOMESTEAD NON•RESIDENT1Al
VALUE VALUE VALUE VALUE
Land not exceeding 1(one) acre immediatety
surrounding residential improvements. (�)
Oiherland (p) �
Total land Qine 7 plus line Z� (3)
Dwelling (4) �
Residential improvements
Garage (5� =
Oiherimprovemenis (6) _
Total improvemenis (line 4 through line � (7)
Total value (line 3 p�s line � (g�
I hereby CeRify the abOVe i5 [Ne. Corrett, and Signature ot Assessor Date signed
complete.
;�rc� action - Signature ot Audimr Da;e signed
SgnaWre ol Audimr
19_Pay19_
;ser of 1/2 Homesiead
va�uauon or �r,.tiuu
S
STATE FORT153�'RJS-09)
.�PPROV.:D BY STATE BOARD OF ACCOU�TS, 2009
TREASlIRE2 FORM TS-IAI
PRFSCRIBEO BYTIff DEP,VtTNEVT OF IOCALGOVER.\'.�Y,� FTA.\CE IC6-1.1-_ 9.i
Indi��iduals and married couples are limited to one homestead standard deduction. As the receipt of this
deduction becomes more beneficial, there is more incentive than ever for homestead fraud. Homestead fraud
�uses higher tas bills for all; therefore, HEA 1344-2099 requires taspa��ers «�ho receive the homestead
siandard deduction to verify that they are eligible to receive the benefit and to pro��ide addition,ll ideatifying
information necessary to allo��� county government to better monitor homestead filings. This iuformation
�r•ill be kept confidential and can only be accessed b�� authorized county officials. The Department of Local
Go��ernment Finance will use this information to create tools that will help county� officials climinate
�
Taoacer \ame
Frank / Marcella Folkmann
Complete and return to:
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Mai4n9 AaOress (nunter an0 streel tlh.
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soaa� seaaiy Nw�ne. ro:t s me�ts)
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MiaCle
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Oriv7s License $ta;e ID N�rtCa (last 5 tllplts) nae
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tarn unaers�gnea ceruues, unaer penairy oi per7ury, that me above antl roregoing fntormauon is we antl correct antl mat he or sne is engible to receive �
homesiead standard deduction on this property. Each undersigned also undersfands that, by daiming additlonal homestead deductions unlawfulty, he or
she may be liable for back taxes and subsfantial finandal penaltles. �.
Umv f Smawre Date TeleM�e -
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