Homestead_GaultneyCLAiM EOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
s� Form 5/73 (R7 � s-o�
Presabed by Ihe Depm6rent d Laol Gaiamad Fe�anm
INSTRUCTIONS: See ieverse side !or filing in�tions.
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�(We) � cerSN t on the `f�t0�' 20
I(We) occupied as ow {u'v�dpal residerce esctbed real poperty fw whirh a Hamestead � tT�it�s dmmed:
�) owned ❑ ae buyug under cantrad � OR
Have a benefidal inffirest m fhe entiry tl�at is liade 6ot Me poperty f�es m the property and Mat owns the property w is buyug under a cantracl
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IF Wy"�g m cantracl Fee Sirt�le wynefa rmma
f�tirdefs d6ce whae ca6ed is recaded Rewd number Pepe
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Legal d�aiptim
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n my �oe� m n�e r�;doai� ar�,�aaa w me �d �a �oe� o�e (�) acre m�:n�a�y �„�u,� n,� �,mre � used m a��:��. d�me me �e m,d oa�uon
or u,e p,operty uti5ma m peoa,oa uw,ie.
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Resae�'vnpfwerenss v avwaly °"�eR"9 (°) '�„�����,�'�s'�f y� i 'M ti"�,�'�'�
Assessed AMWe / Alarwfemred Home ` W'�� `�4'+�['`Cy��F.n ��TM
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TUeI trnprwernerNS (Ime 4 t/vou[� 6ne b) �7�
Tdsl value (/ine 3 phs Hne � �g)
I Aereby certiy fAe abwe is hue. carrecf. and sierc�se oFAga�sv Dffie s'gied
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Naifycg actia� - Si�gm4se N/4MSOOr DaOe apned
i'� ��! ,�: +0�1��,;:STMlDARDDEDUCTIOM/LL:LOWANCE:t��,..i��:;i", s'+�-.r�,�,: r�KYt:�'k�;°;.�
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20 _ Pay 20 _
Lesser of 12 Horte�ead
Vadiatim or f35.000 S
Si�ue of a�mr Dete sipned
SfATEfORA(51569(R3B-10) �� TREASUItERFOft.NTS-IA
APPROVED BY STATE BOARD OF ACCOII\TS, 2009 PRESCRIBFD BY iHE DEPMT��.YT OF IACAL GOVERNNEI.T FIRA\CE ICbl.l-22-A.1
Individuals and married couples are limited to one 6omestead standard deductioo. As the iieceipt of this
deduction becomes more beneficial, there is more inceutive than ever for homestead fraud. Homestead fraud
� causes higher tax bills for all; therefore, HEA 1344-2009 requires taxpayers who recei��e ttie homestcad
standard deduction to verify that they are eligible to receive the benefit and to provide additional identitying
information necessary to allow county government to better monitor homestead filings. This information
rvill be kept confidential and can only be accessed by authorized county officials. The Department of Local
Go�•eroment Finance �vill use this information to create tools that will help county officials eliminate
homestead fraud.
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Tuna.en\ame Procem' Address Stale Partel Yvmber Ln_al Dncrintinn:
BrianMGaul�ney ��SSPRINGST 26-11-12-400-OOL528-02i PTSE 1??II A92?AC
PRINCEOTTJ IA' 476i0 - � .
Complete mtd ieturn (o: �!� � E�! �!� E�� I
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GIBSON COUNTY AUDITOR, 101 N MAIN PRINCETON IN d7670
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Owner 1 Firat MbEle Last
Q R. i A Ri �. �A w ��F'nl �`'f
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MaJUp AaWeu (runeer arw sUeal cM1y, state antl 21P coEe) � Same as pr[rperty ederess
y�+� s. �' a,�'� S-rr�e�.t. P�,;N��n, �����o
Sorial Senruy NianDer �last 5 Elglh) DrivMS Litmuel5tate 10 Number (lut 5 Clglla) '+�+�^ 011ier (please apacily vi Part a b¢bx) . .
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Soouse . . . �' F'ust MbEle Last
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Mailirp f�Cress (number aM svoet, ory. slate aM ZIP cada)
N�� ��1 Same as poperty eCaress
LJ
Sadal Sea+Yy Numcer (last 5 Elglb) Driveh Licansa/51ab ID NumDer (last 5 EIBIb) �� �'� (pease spwty m Pan a p¢low)
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Eacb.undersigned certifies, under penalty�oPperjury, that the above and foregoing information is true and wrreG and thaf he or she is eligible to receive the
homestead standard deduaion on this property. Each undersigned also understands that, by Gaiming additional homestead deduaions unlawfully, he or
she may be tiable for back tazes and substantial financial penaliies.
Ox�nx 1 Sipnaere Date
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