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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Form 5473 (R2 / 5-92)
INSTRUCTIONS: See reverse side (or /iling instructions.
FORM
HC10
YEAR
1 -
j CERTIFICATION STATEMENT
� I(VJe) certify that on the 1 si day of March, 19_
� I(W upied as our principal place of residence the following described real property for which a�Home��'Prpp�t�'�redit is hereby claimed:
I(We) owned ❑ Are buying under contract .
❑ Have a beneficial inierest in the entiry that is liable for the property taxes on the property and th wns th pr e is b' u r a contract.
n� ��TV CliflT
CONTRACTRECORDED ' y
It buying on contract, Fee Simple ownefs name
Recarders office where contrect is recortletl � Record number Page
. PROPERTY DESCRIP O
Counry Township Ta�dng i i" .., ta ship) �
pyr n/mber_ ^ n^�' O Legaldescription
U �ti � .J U oi
If arry poNon ot the residenGal sWMUre or the lantl not exceeding one (1) acre U�at immediatety sunountls thai strucW re is usetl ro produce income, descnbe ihe use and portion of
the pmperty util¢ed ro produce income.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Township Counry shi
� I
� Sign r ot ciaimanl
�reby certify the above statements are true, correct and complete. '
Adtlre (number ndstreet, ciry, state, Zl eJ /�
�y_C.% S/%(o
ASSESSOR USE ONLY TRUE TAX , ASSESSED �HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land not ezceeding 1(oneJ acre immediately (�)
surrounding 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 Ihe above is true, CArtect, and Signature of Assewr Date signed
complete.
Venfyinq action - Signature of Auditor Date signetl
STANDARD DEDUCTION ALLOWANCE
� 19_ Pay 19 _
Lesser of 7/2 Homestead y
V luation or 52,00
Signature of Auditor Date sigrted Q�
J' �v
SfATE FORM 5)569 (R3�&IO)
APPRO\'FD BY SfATE BO.VtD OF ACCOl7\T5, :009
fRF�15URER F00.0 TS-IA
PRESCRIBED BY THE DEP.VtT\4E\T OF LOC.LL GO\'ERN?Ip T FIBd\CE ICFI.I"_�8.1
Individuals and married couples are limited to one homestead standard deduction. As the receipt of this
deduction becomes more bencficial, there is more incenti��e than ever for homestead fraud. Horaestead fraud
i�auses higher tax bills for all; thereforc, HEA 13d�-2009 requires taspayers �rho recei��e the homestead
� andard deduction to verif}' that thc�' are eligible to receive the bcnefit and to provide additional identifying
information necessary to allow counh' government to better monitor homestcad filings. This information
�vill be kept confidential and can onl�' be accessed b�� ruthorired county officials. The Departn�ent of Local
Go��ernment Finance will use this information to create tools that will help counh� officials eliminate
homestead fraud. '
Ta�nacer �ame
Florena K Perkins
Complete and renon to:
.�T?i
Sodal
SVcet
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�ad�a �_�
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� Same as proparty aCtlress
Drivefs licensNSta:e ID NianCer (last 5 tligi[s) �� 0'Jrer (pleax sper2y'v� fah a pelow)
- " � u�.�l.S�i�ac�;�w�l.riio.ily �
Each undersigned certifies, under penalty of perjury, that the above and foregoing inforrsetion is true and wrred and that he or she is �ligible to receive i
homestead standard deduclion on this property. Each undersigned also understands lhIOF? by claiming additional homestead deduction� unlawfully, he or
she may be Iiable for back taxes and substantial financial penalties.
O.vner 1 Syna.ve Da;e Te�eM� '
Spouse Sgnature
Date
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