Homestead_HennessySTATE FOR.\f U569 (IUIe-10) 'titE.1SURER FOR�f TS-IA
MPROI'ED BY' STAiE 90ARD OF ACCOL'�TS, ?009 PRESCRIBED BY THE DEPAR'f}fE�T OF LOCAL GOl'ER.�IfE: R Fi�.�\CE ICbl.l-22�8.1
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Indi��iduals aud roarried couples are limited to one homestead standard deduction. As t6e receipt of this
�^�iuction becomes more beneficial, there is more inceotive than ever for homestead fraud. Homestead fraud
•auses higher tac bills for all; therefore, HEA 1344-2009 requires ta�payers ��•ho receive the homestead
standard deduction to verify that they are eligible to receive the benefit and to provide additional identifying
information oecessarv to allo�r• counh� go��ernment to better monitor homestead filings. This information
will be kept confidential and can onh� be accessed b�� authorized count�� oft"icials. The Department of Local
Government Finance ���ill use this information to create tools that will help county officials eliminate
homestead fraud.
Tvoarer \ame
/ Janna Hennessv
Cnmpfete and return to:
Last
�e,r.ressy
��ama as property �tlress �
Oeivefs License/5ta:e ID NumEe� (last 5 tllgits)
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�I O:hm (Wease speufy in Part a Eelow)
IV
Each undersigned certifies, under penalty of peryury, that the above antl toregomg mrormauon is «ue ana wrtea ana mac ne or sne is engioie co recerve me
homestead standard deduGion on this property. Each undersigned also understands thai, by claiming additional homestead deductions unlawfully, he or
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P,AR�T 4: ARDITi1QY.aL I�IF.QRMATi�ON
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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Fortn 5473 (R2 / S92)
INSTRUCTIONS: See reverse side lor filinq instructions.
FORM YEAR
H�-�...T ��'�
�
� ��
NO'� •
r CERTIFICATION STATEMENT � � �
� /
I (VJe) ` � certify that 0 (he-1s1-day�W,Ivlarch7{18��
n�ze . �: -r ' �' !
I(We) occupied as our principal place of residen e foliowing described real operty for which a Homestead Property Ta�c�Cred�i� ishereby�claimedTC3
�(We) owned ❑ Are buying under contraci
Have a beneficial interest in the entity that is liable for the property taues on the property and thai owns the property or is buying under a contract.
CONTRACTRECORDED
It buying on conVac[, Fee Simple ownefs name
Recortlers otfice where conVaci is recorded Recortl number Page
PROPERTY DESCRIPTION
Counry Township Tauin isMd (ury, t , township)
Parcel number legal description
(� o - oa - .
It any portion ot ihe resi0ential structure or fhe land not exceeOing one (7) acre that immediatety surtounds ihat suucture is used to produce income, tlescnbe the use antl portion of
Ne properry utilize0 to produce income.
- � PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry TownShip Counry TownShip .
Signature oi daimanl
�reby certify the above statements are We, correct and complete. _
Address (numbeiarrtlstmet, ciry, sfate, ZIP code) '
RR R�v zoz ruceroV iN �/767G
ASSESSOR USE ONLY TRUETAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land not exceeding 1(one) acre immediately (� �
surtounding residential improvemenis.
Oiherland (2)
Total land (line 7 plus line 2) (3)
Dwelling � (4)
Residential improvements
Garage (5)
Oiher improvements (6)
Total improvements (line 4 througA line 6) (7)
Total value (line 3 plus line 7) (8)
I hereby certify Ihe above is true, correct, and Signawre of Assesor Date signed
complete.
Ventying acGOn - Signature of Audiror Date signed
�- STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _
' Lesser of 7/2 Homestead � $ �
Valuation or 52.000 .
Signature of Auditw �/ Dat� signed
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