Homestead_Moore (7)"'^ CLAIM FOR HOMESTEAD PROPERTY TAX
# STANDARD/SUPPLEMENTAL DEDUCTION q
s.V State Porm 5473 (R721699) . � �
�' / Fmuribea ey u,e oevaN�nt ot L«a� co�remmern Frenca
� INSTRUCTIONS: See iererse side /orfilirg insfructions. ��' �
FORM
HC10 •
YEAR
I(VJe) �����L,�.y �4 jyy1.Q/1��• Q� Y Y lLrYJ LS+- certify that I(we) ocwpied as my (our) prindpal
pla�idence or am (are) buying the following described real property for which a Homestead Property 7ax Standard DeducUon is hereby daimed
under Vact on Ihe date this appiiplion is filed, (date of fiGng):
(We) own ❑ Am (are) buying under recorded conVact
❑ Am (are) entitled to occupy as a tenant-slockhalder of a cooperative housing corpo2tion
� Have a benefidai interest in lhe Wst or the right to occupy the properry under the terms af a qualified personal residence wst
(lepal name)
F..nl
o/ daimant (Wsf frve tligiLS)
(lastlrva Oigrts) I Drivers ticense / Identl:rcatian / Othe�
01 daimarrt's spause (la9 fire
11 Wymg rn conbact, Fee Simple owners �me
RecoNefs o(fKr where contrecl is recaded
Counry Ta
row�.
Ue D�PertY in 9uestbn:
Recartl num�er � Pa9¢
' I e1" 1 p"'1 U�i'UtAJ AJI-DoZ '� � U RealO�vertY LJ AnnuaOy assessetl rtroWe hane (IC bf. f-;
If any portion W the residenWl sNxwre u 1he IaM nW exreedUq me (1) aae Na[ immediaNJy surtwrMs thal strum�e is used tn pmduce Inmme, desaibe ihe ute aM pwibn
of Na pioperry utP¢ed to praduf¢ uvrnrre.
Counry
Township
I hereby certify fhe above statements are we, correct and complete.
Pddress (num6er aM street, rify, sfate, and ZlPtade)
Lane not ezceeding 1(one) acre Immetliatey
Otherland
ToGI land (line 1 plus line i)
Residential Improvemenb or Mnually �����9
Assessed Mobik / Manufaceired Home Garage
Other Improveme�
Toql improvemenis (Ilne 1 Nrough Ilne �
Total value (llne 3 pf�a line �
� I hereby urtify the above is We, cortect,
and complete.
Veifyi� aam - SignaNie ol Audimr
i�)
lz>
(3)
ia)
(5)
(6)
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IB)
SgruNre of Assessor
Caunry
20 _ pay 20 _ Lesser o! 60% ot the assessed value of Ne homestead or $45,000
NotwtthsfaMtrg any ofhei provision. Ne wm oI Ne deductians providetlln IC 67.7-1210 e mo6de home Nat fs $
not essassed es mal propeMor lo a menufaGUred hert�a Nat'a nat assessed as real poperty maY �t erceeA
wiahaB(iRl o/ fhe assessed relue d Ne mobie Awrie orrtunNarluree hwne.
SlgnaWre alPutlitor �
Townslup
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TiCsg '�`�s'' �\
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Date signed (rtronN. daY• iea�
Dete 5igneC (monN, tlay, yea�