Homestead_Gayer�
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CLAIM FOR HOMESTEAD PROPERTY TAX
, STANDARD / SUPPLEMENTAL DEDUCTION
�r StaleFortn5473(R72/6-09)
�° � PrescnbM by Ne Department o( Loml Gavemrnent Frmnce
INSTRUCTIONS: See raverse side for fif'ug inst/uctions.
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FORM
HC10
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I(We) certiy that I(we) occupied as my (our) prindpal
place ot residence or am (are) buying the follo ' described real property for which a Homesiead Property.Tax Standard Deduction is hereby daimed
under conVact on Ne date Ihis application is filed, (date olfiling):
❑ I(VJe) own ❑ Am (are) buying under recorded conVaa � ,
❑ Am (are) entilled to occupy as a tenant-stockholder of a cooperative housing corporation
� Have a benefidal interest in the Wst or the right to occupy the pmperty under ihe terms af a qualified personal residence Wst
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Nam of deimant (kga/ neme)
Sodal Seamry nmta af dacront ( frve d'git DrivnJs firense I Itlrnti: �� , Isw'ug Sate
/ � � � of tlaimant (last five tligiLSJ �
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Name ot da'unanPs spouse (lega/ neme)
Sadal Seariry numEC W Ua'unanYS spouse (las( five dig'4s) Drirefs Gcense I Identifintian / ONer number Issuing State
ot ciairtram's sv�se (Ws! flve dlyrtsl .
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If buymg m mntraq Fee Simple ownefs rume
Remrders af&e where mntreG is recaded Remrd number � � Page
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Counry Tamship Tadng d'atri riry, bwn. i0)
Paicel number al desoiP� • ' Is Ne p'operty m question:
8 ❑ Real property ❑ AnnwOy assessetl modle home (IC 61.1-7)
Ii any portion of Ue resdenUal struc¢��e or the IaM not exceedi� wre (1) aae Nat imrtretliately surtou�MS UNat sWChira is used to pmduca inmme, Eescnbe the use anE portion
of Ihe pmperty uhT¢ed ta produce inmme.
�a�'l(-/���foo-Do3,i��-oa7 D-i7
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Counry Township � Caunry Township
I hereby certify the above ststements a2 We, cortect and complete. Signawre oAl �daima�m� �
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Addreu(numDerandshaef,dry,slete,andLPOOd /^yC/WWWr
) 7 5 3 q'U (N i
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Und not e:ceeding t(one) acre ImmeAlately ���t�,���� � �� '
surtoundin residentialim rovements. ��) -�Ls.a��s��.,u�: .'��:�:�
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OtherlanC `s
�t� a
�Z� - ..:;±c�2��.'i`ic.-�I3y��
Tofa1 lane (line 1 plus lina � (3)
Dwelling (4) ' ' C_�+g.-°��`A'�L�S;:�S'ii�.�� �
ResidentlalimprovemenborMnualty �_ -+'��^'-�r.`�-.u���'��
Assessed Mohik / Manu(acWred Home �-,��s.tt"� �`=S �" i� �.ii Y"° �.
Garage (5) :h:'s7`^�`-���r�7`�.:5�k`�`.
�y��;..,a.�ym.�.,-.�
Other improvemertb (6) ' ?;Y.: ;�'�.�i=`r'='i=�x
Total imp�ovemenb (line I rhrough line � (7)
Toni �ma pme � ai� ir�e n �e�
I hereby certity the above is We, wrtecl, Sg"a� °���'� ��� (��' �Y ��
and complet¢.
VO�h'IMJ BCflp1- S19118111R O�/Wd�INf �diG S1011Cd IRIOIIi�I. (�dY JCd1%
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20 pay 20 Lesser of 60% of the assessed value of Ne homestead or $45,000
NoMithstantluy enY �erprovisior�, Ne swn W the deducfiens po�dded in IC 57.7-12 ta a rtmb➢e frome Nat Ls $
not essessed as real propBrty a to e men(rfettulBd horra (hat k no( essessed as iBel plDperty may rpt exceed
one-hatl (/2) d Ma essesse0 rdhreW Ne mobde Aome w manufawrtM hwne.
Signature olhWitw n Date signeO (mmN. day, yea�
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