Homestead_Koberstein (2)rescribed. By State tioara ot '1•ax t:omnissioners rA �
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CLA1M FOR H(X��STEAD PROPERIY TAX CRmIT FOR YEAR 19_ �-I'�
SEE BACK FOR FILING.INSTRUCTIONS
I�`..��e� ��i�,����� �� certify that on the lst day of
"•`�, 1° , I, (F7e) occimied' as our princiDal lace of residence the follaaing described real
r��rty for whicn a Hm!�estead �o�sty Tax �e � t is hereby being clain�ecl:
Z, (Tti*e) � aana3 /,,
� are buyinq urrler wntract ' 0 � �y ��' ��
� have a beneficial interest in the ta�qx3yer . ��
Pronerty Description in �/�� �,�✓ � tY TaanShiP
Taxing District (Gi�}'-._Ta:�n, ?bc�mship) : �i����;,�J
Parcel Clwnbex or legal description shown on tax statenent:
�� /11 � � � /.'� — � - //7 i� IoSS
If buvina on �ntracti O�mers nan� (fee sirtrole owner)
Contract recorded in Remn9er's Office - Recard No. Page
I= any portion of the residential structure or the land, not e�eeding one (1) a¢e that
imnediately surro�is that structure is used tn pn�duce incane, describe the use arzi portian of
cne pxvperty utilized to produce i�ome
fny other �wities in which individual o�ms or is.buying real property: � Countv Zbomshio
?�,�xeby certify the above state��t is true, �rrect and co�lete.
�
*Signature � Street Address City, State and Zip Code
*Individual either v�ms or is buying tmer a o�ntract that provides he is to pay the
property.taxes on the_residence, or has a beneficial interest in the.taxpayer.
- FOR ASSESSC�2�S USE ONLY -
Land not exoeeding 1(one) acre inm�ediately
surmunding residential i�rovanents
other Lana
Total Land
Pesiaential I�rovernnts
Dwellinq
Garaae
2bta1
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- . .
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othes improvanents (7) /�
Te �; 7�rovements - Line (6) plus (7) eauals (8) (B) / � d 3 a�o
Z nereby certify the above is true, correct, and anmlete.
Date
- ACTION BY P.UDITnR -
v..^�roved: Date:
STAiE FORN 57569 (IU/&10) iRF.15URFA FORA1 iS-IA
MPRQ\'ED BV S�'-\iE BOARD OF ACCIX1hT5.:009 PRESCRIHFD BY THE DEPAR'lNE�T OF LOGLL GO�'FR�'WiM Fl�a�CE ICa1.13?-8.1
' / � ' / , , . 1 1 � , I • , � "
Individuals and married couples are limited to one homestead standard deduction. As the receipt of this
�aduction becomes more beoeficial, there is more inceotive than ever for homestead fraud. Homestead fraud
�causes higher tax bills for all; therefore, HEA 1344-2009 requires taxpayers who receive the homestead
standard deduction to vecify that they are eligible to receive the benefit and to provide additional identifying
information oecessary to allow county goverument to better monitor homestead filings. This information
will be kept confidential and can only be accessed by authorized county officials. The Department of Local
Government Finance will use this iuformation to create tools that will help county offcial� eliminate
6omestead fraud. `
Tamaver \ame
Timothy R/ luiia M Koberstein
Coinplete and return to:
o..br ,
7%.�+.,. o f-/, c.
MaJinp qoaress (nmeer ene so- aty, stete
l98 S D��'.�
SotialSOwriry NunOm (lazt 5 N9its)
� ? �'
xmation is true and wrreG and that he or she is eligible to receive the
that, by claiming additional homesiead deduMions unlawfully, he or
�
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- NOV� T 6 2012
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GIBSON COUNTY