Homestead_Heidenreich Farms IncCLAIM FOR HOMESTEAD PROPERTY TAX
__ � STANDARD / SUPPLEMENTAL DEDUCTION
" State Fortn 5473 (R13 / 12-09)
� � Prescribed Cy Na DepartrnaM of Loral Gwemment Finaxe
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INSTRUCTIONS: See ieverse sJde lo� filing ins6uctions.
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DEC 2 9 2011
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I(We) certify that I(we) oaaiPl�d a�y (our) principal
place of residence a am (are) buying the fdiowing described real property for which a Homestead Property Ta�$��a��9e�d�¢Up,Q�f�Y daimed
Gi
er contract on the date this appli�ation is filed, (date of filing). I(We):
Own ❑ Am (are) buying under recorded conUad
Am (are) en6lled to occupy as a tenant-siockholder oi a cooperaGve housirg corpora[ion
❑ Have a benefidal mterest in the wst or the right to occupy the propeAy under ihe tertns of a qualified personal residence Wst •
❑ Am (are) the shareholder, partner or member of the enGty �hat owns the property.
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Name of daimant (legal nama) ' �
C el e rei
S�y ��
of daimant (latt frve d.gitsl
Name ol delmanPs 5 )
Sodal Sewriry num6er ot da4nanYs spouse last five d'gtts) Drivers licerse / Identlflratbn / Other number Issui� 9ate
o( dalmanYs spou,c (last (rve dgi7s)
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If buying on contrdct Fea Simple ovmers �wne
Reoorders of6ce where mntract is recortletl Record number Page
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Counry TownshiD T (c+h: w�, rownshlG)
Pafmi number Legal desuiption Is the property in Question
1 property � AnnuaDy essessed mob0e Inrtie (IC G7.1-�
If arry portion of the residenUal strucNre or the IaM nol exceeding one (1) acre Nat Immediately w tls Nat strwiure is used to P�uce i�ome. Cesaibe Me use aM pottion
a ma ^x� m w�� ��wRre.
�oS �o- /l - O �3 -
• ac� � Sy go a � ,�
... . . : . .
Counry TwmsNp CountY TowrWJp
I hereby certify the above sfatements are We, correct and complete. Sgnawre daim nt �
k.,
aedress(nu ne�e sveacrih.uere,anenPOOee) INC.E�K! /c/ �-/7 7
�C o2�7�w �De n� P� � 6 0
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Land not exeeeding 1(orre) aore immedlatey �ur �-�R� �� t�'i� r. :-�:
s�vroundin resldenUallm roveme�rts. ��) 3�{•+' y-`^.-'� - -
{ ..:i;4kK_",�...at. �=
Othar lantl (Z) J a� i�'Z..,.: ,
Toml land (line 1 plus (Irre 2) (3)
' s's � �A.i { �v �sg 't�j x�
ResideMial Improvements orAnnually �IIIn9 (4) �n _,s. ,,,.3�i e,q, c-�,;,�f .,
ASSeased Moblle / Manufach�red Home G�9e (5) �-a.:'�i-S'� � �,k,. _. �;1�� �;� y=
. .xF_. S G.. �
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Other Improvamanm (6) � �� ' �'" ; .
Totel improvemeMS (Ilne I Mrough line � (7)
Total value (Ilne 3 plus line 7) (8)
I hereby certify the above Is We, correet, �9"a°�re ot Assessor Date si6�d (^ro^N. deY• Y�
and complete.
Veifying aNOn - SigrraWre of NMibr Dale signed (monN. day, yee�
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20 _ pay 20 _ Lesser of 60% af the essessed value of the homestead or $45,000
NoMiMStard6g any otfrerprovision, Ihe sumW fhe deductions provided in IC &f. f-12 to e mobile twme fhat is $
not essesse� es reel propertyor ro e menufactured hwie fhet is not essessed es real property mey nof exceed -
o�,e-nen �irz1 aure es�d �nre w ere moaaa r� of��w��a r�».
Signewre of Auditor . Dat�sig (month, tley, yean/
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