Mobile Home_Hunt (5)""' CLAIM FOR HOMESTEAD PROPERTY TAX
S, _ . _, STANDARD / SUPPLEMENTAL DEDUCTION \I (),_,
State Fortn 5473 (R72 /609� \ � Q •
y,�� � Prescnbetl by Ne Deparimeni of Local Govemmenl F�ance
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INSTRUCTIONS: Seeleverse side /orfiling insaucfions. �
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I(We) certify that I(we) occupied as my (our) pri�pal
place ot residence o m(are) buying ihe following described real propeAy for which a Homestead Property 7ax Slandard Deduction is hereby daimed
under conlreG on th date this appliration is filed, (date olfiling):
❑ 1(We) own ❑ Am (are) buying under recorded conVact
❑ Am (are) enlitled to occupy as a tenant-stockholder of a cooperaMe housing corporation
� Have a bene(dal interest in the wsl or the right to occupy ihe proDerty under Ne terms of a qualified personal residence Wst
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Name of daimant (legal narne) _/� 1 .—
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SooalSmirity of t(fasl fise tlig3) D`ivers fi�nse / Identfxsiion / Other number Iswi'q State (/
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Sodal Secunry number of daimanYS spouse (last lrve dgits) Dm�ers frxnse / Identifmation / Other number Issumg 9ate
ot daunanCS spouse (/est �rve dgits)
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It buying om m�tracL Fee Simple ov.nels �me
Remrdefs oRxe where tontract is recorde0 Remrd numCer Page
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�nry TovmshiP Tadng dis �(ciry, town. fownship)
Pa`crJ number pL�.g�al desaiPtron �j .2. g�% 8 fa � Is ihe property in qu�tion:
' I J S� � � � � Real ProGertY ❑ AnnuaAy sssessed modle home (IC G1.1-7)
�tt any portion d Ne residentlal sWCNfe or Ne WM not esceed'ug orre (1) atre Nat irtunetliatety surtounds Iha[ swcNre is used to pro0uce irrowne, des�ibe the use aM portion
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Counry TrnmshiP Caunry Township
I hereby certify the above ststement5 are W e, correG and complete. Y Signature oi da ant �
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Address (numDer an0 street. dry, state. and LP ootle) �D � � � � � /'� 1 �� � �y �
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Landnote:ceedingl�one)acreimmediately {+yG�.,. +�'�:�'�` `��3e' ��-r
sunountlin res(dentialim rovements. (�) ��`=���"�h!-'•,'�`'�'�'"'� -?���%�
.�� c. .. �_ �-s„
: cri'�,�i=�.'i�:�i?t. � -.r=
Otherland (z) i`':��-�;�';.ir...?:�':.�: �
7ota1 land (line f plus line 1) (3)
7#"'3�tsr Y` �"�-.°.a.t : „i_ie:�
ResidendalimprovemenfsorMnuaity ��ling (4) ;,,'ii..�.yx. �„���.y�Y}-�.�F,1y`
hssessed Mobile 1 Manufactured Home �"" t�� ''?'�'� � k�±'
Gars9e (5) itii. �'v �����,.*''NYi:si`�Ci
'+?':a'..�i�;S'i?,:`:7i"�?ti�. _
Otherimprovemenis (6) -- , r�?e. _
Total improvements (llne 4 fhrougA Ilne � (7)
Total value (line 3 pl�s line � (8)
I hereby certity the above is true, cortect, Syriahire of Pssessor oate signee (rtronN, day, yea�
and complete.
va�rr� armrn - signayre or a�eiror Datn s9ned (mmN. daY Y��
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20 _ pay 20 _ Lesser of 60°6 of the assessed value of the homestead or $45,000
No(wilhslaMing eny oiherprovision, Ne sum oi Ne tletlucfions pruvided in IC 67.1-12 to a rtrobde home Ihat is $
not assessed as ieel properry or to a menufeaured home Wt is not esseued as real properry may rmt exceed
ona-hatl (f2) ol Ne a55essed rdlue a/ fAe moblle home wmanuhUU2d hame.
SynaWre W Auditw ^ � Dace si9neG (monN. tlaY• l'��)
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