Homestead_Peters�,+ °•n
� � CLAIM FOR HOMESTEAD PROPERTY TAX
r� CREDIT/STANDARD DEDUCTION
State Form 5473 (R2 / 5-92)
���1
INSTRUCTIONS: See �everse side lorliling instructions.
. • ° , ° - . , -. . . -�� c�r+n�can
FORM
HC10
YEAR
�(Hre/{!�� v�/� �i/C.. cenity thai on the 1 st day �o�tT4ar2F�, 19_
�`^+�) occupied as our princip I place of residence the foliowing described reat property for which a Homesiead Proper� �eB�t i�by daimed:
I(We) owned ❑ Are buying under contract
❑ Have a beneficial interest in the entiry that is liable tor the property taues on the property and that owns the operty or is yi nder ntr t.
��✓ , ) ,
� ���__,�.;,:�0_.•:;Ya.UDiTOR
. _ .. , . CONTRACTRECQRDED`. .•_�.._ t;_. .i•��c`r�, e` ---�,et'.
If buyi�g on contrad. Fee Simple owners name
Recorder's oHice where wntract is recortletl Record number Page .
Counry �r� � Township � �� Taxing tllSMCt (pty, t ,���� �
// � LCJ
Parcel nu ber Legal descnption
�p� - oo7%J =ac�
It any portion ot ihe resitlenfial struaure or the land not exceeding one (1) arse that immediately surrourids [hai structure is used to produce income, descnbe ihe use and portion
of the properry utilizetl to produce income.
Counry
PROPERTY OWNED BY
certify the above statements are irue, correci and complete.
numberaridsheeG ciry, state, Z/Poode)
� , � ASSESSOR USE ONLY ' �
Land not exceeding 7(one) acre immediately
surrounding residential improvements.
Oiherland
Total land (line 1 plus line �
Dwelling
Residential improvements
Garage
Oiher improvements
Total improvement5 (line 4 through line �
Total value (line 3 p�s line �
I hereby certify the above is irue, correct, and
Complete.
Verityirq aIXion - SiqnaNre of Auditor
19_Pay19_
lesser ot 1/2 Homestead
Valuation or $2,000
L
C 2 f0�
TRUE TAX
VALUE
I�)
(2)
(3)
(4)
(5)
(6)
l�l
(8)
Sgnature ot Assessor
Counry
5
ASSESSED
VALUE
HOMESTEAD
VALUE
Township
NON-RESIDENTIAL'.
• VALUE •�'.
- F "
Date signed
tev5p netl
Q �S
.+
STATE FOAN 53�69 (RLB09)
APPROVED B1' STATE BOARD OF ACCOII�TS, 2009
�TRFASURER iORM TSIAI
PRESCRIBEDBYii[EOEPMTME�TOFt.00Ai.CAVFR\NITFINANCEIC61.1 �?-H.1
Indi��iduals and married couples are limited to one homestead standard deduction. As the rc�ceipt of this
deductioa becomes more beneficial, there is more incentive than ever for homestead fraud. Homestead fraud
�auses higher tax bills for all; therefore, HEA 1344-2099 requires taxpayers ���ho recei�•e the homestead
standard deduction to verify that they are eligible to receive the benefit and to provide additioual identifying
information necessary to allow county government to better monitor homestead filings. This information
�r�ill be kept confidential and can only be accessed bp authorized couuty of5cials. T6e Deparhnent of Local
Go��erament Finance will use this informatiou to create tools that will help county ofGcials eliminate
homestead fraud.