Homestead_MerrillSi�Ip
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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
SUte Fortn 5473 (R2 / S92)
INSTRUCTIONS: See reverse side lor /iling inshuc5ons.
FORM YEAR
HC10
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CERTIFCATI STATEMENT
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I(We) c rtify that on th 1 st/d�a,y� of M ch, _
I(We) occupied as our principat place ot residence the tollowing described real property for which a Homeste Pro� re�yt�,l�ie'�t-� imed:
❑ I(We) owned ❑ Are buying under contract C,�ggON COUtd��� "���� �� �
❑ Have a beneficial interest in the entiry that is liable for ihe property taxes on the property and that owos the property or is buying under a contract.
CONTRACTRECORDED
II buying on contract, Fee Simple ownels name
Recordets office where conVact is recorded Record number Page
PROPERTY DESCRIPTION
Coun Township � - Taxing disirict (�ry, t� , f shi /7
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P cel num er leqal tlescripti
�5o�,-oa � a 3
I( any portion of Ihe residen5al s[ructure or the land not excee ing one (1) acre that immetliatey surtounds that strucW re is used to pro uce income, tlescri0e ihe use antl ponion of
Ne property utilized to produce income.
- �PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Tovmship Counry Township
Signature of claima �
.ereby certify the above statements are true, correct and complete. S�
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A tl (nu �and stre G ciry, s ate, ZlP wdeC; ) i�
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ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land noi ezceeding 1(oneJ acre immediatety (��
sunounding residential improvements.
Otherland (2)
Total land (line 1 plus line 2) (3)
Dwelling (4)
Residential improvements
Garage (5)
Other improvements (6)
Total improvements (line 4 through line 6J (7)
Total value (line 3 plus line 7) (8)
I hereby Certify the above is true, coneCl, and Signature of Pssesor Date signed
complete.
Veritying action - Sgnamre of Auditor Date signcd
STANDARD DEDUCTION ALLOWANCE
� 79_ Pay 19 _
Lesser of 1/2 Homestead S
valuation or S2.o00
Si ture ot A imr oate s" n
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STATE LO0.N $i 569 [d_ / i {r/�
TFFASIIl£RiCRMTSIA
APPRO\'FDBYJMiEBMiDCFACLOU\'!5.![09 PRESLllOm 9YTHE LFPMIA�£Yf Cf LOCALG044A\'�ti\i k4:NCE C61.I.••.B.1
Individuals and married couples are limited to one homestead standard deduction. As the receipt of this
deduction becomes more beneficial, there is more incentive than ever for homestead fraud. Homestead
�fraud causes higher tas bills for all; therefore, HEA 1344-2009 requires taspayers �rho receive the
homestead standard deduction to verify that they are eligible to recei��e the benefit and to provide
additional indentif}�ing information necessan' to allow counh' government to better monitor homestead
filiugs. This information will be kept confidential and can only be accessed by authorized cou�t}� officials.
The Department of Local Government Finance will use this information to create tools that �r�ill help
county officials eliminate homestead fraud. �
Address (number and svee4 ciry�, state, and ZIP code)
ia9� .s c�°Q
Parttl \umyer
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Address (number and sveet, ciry, state, and ZIP code)
Pan 4 below)
� Sarne as property address
specify in Part d below�)
under penalty of pery'ury, [hat the above and foregoing in(ortnation is true and mrtect and that he orr
ste tandard deduction on this property. Each undersigned also understands that, by claiming add��
H II he or she may be liable for back taKes and substantial financial penalties. �
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