Homestead_Slunder (4)CLAIM FOR HOMESTEAD PROPERTY TAX j�� �� fORM �R
STANDARD/SUPPLEMENTALDEDUCTION
State Fam 5073 (R13 / 12-09) HC70
� � PresaiDad by iha Depanmant of Local Gwemment Finaxe � � �� L U i Z
INSTRUCTlONS: See reverse slde Ior fiGng ins6vctions. C. J. h'�.�-�,�y
. �
I(We) Y � that I(we) oaupied as my (our) prindpal
place of residence w am (are) b'ng.the tdlowing described real pmperty for which a Homestead Property Tax Standard Deduction is hereby daimed
�er contraC on the date this application is filed, (dafe of filing). I(We):
Own ❑ Am (are) buying under recolded conVacl
Am (are) enGtled to occupy as a tenent-stockholder of a cooperative housing corporelion
❑ Have a benefidal interest in Me trust or the right to oaripy ihe pmperty under Ne terms of a quaiified personal residence Vust .
❑ Am (are) ihe shareholder, partner or member of the entity that owns �he property.
�. , �
N 1 ) n
1 /\ l�i � .� I /
l��I I(..lJ(..0
Sodal SeauitY of Uaimanficanse /� ����im / Other I� �� �
Na of ei nPs s (legal me)
soda� sewritr numEer ot aa'vnanrs sv�e (last rNe aigrrs) omers 6rerrse � mentmfatan � aner
/ 1-
� �•� �
If buy'ug om m�vact, Fee Simple ownets name
Recordefs ofiw where contracl is recwded Recard numbrs Page
•�• � �
�„ rownsniv reriny asa�u (car ro ro p
rtgl wmber Legal tlesaiPtlon Is P�oP�Y in 9uestim:
- -3S3cz�—o l.��S-oa ��� ❑�,��„��a�����.,.,-n
If arry P�� of the residential sWClura w the Iar�E not e�ceeding a�e (1) afre that LnmetliafeJy surtounds Nat stru�re a used to P�oduce inmme� tlesaiba Ue use and Portbn
W Ihe pmperty utii'¢ed to proAUCa incortre.
�
• � • � � : � •
Counry TownshiP Camry •. Tow�sM7
I hereby certiry ihe above statements are We, correct and complete. `e��� .(1
LQ,�
number enA strae(. ary, state. ard ZIP e �� � �^ �� O
d /
�• �
• • • � • �
��• �
..�. M' r.�v.. vy.� y s�} >
Land not ascaeding 1(orre) aere 4nmedlately � +� z.� �--�,,i ��.,-�ys �;
wrtoundi resldenUal Im rovements � ) �: � � .-r- -r...; f _ .1. �. , �
xF ;e r.,� �, '
Otherland (2) � �„�-?�. ..
Toml land (ltne 1 pl�s line 1) (3)
.+"'.�� . s..,ry �_
Residentfal Improvemenfs orAnnuafty �Iiing (4) ?Y'l�yF;.;t :.�-,,�-,,�+,y�� �.Ty��F
Asseased Mohtle / Manufac�red Home �,arage (5) ��?3�t'�� n..�?��., �� ��p zi
Other Impravemenffi (6) � � u,�,`•-F $��-.�-
Total improvemenh (Itne I Mrough line � (7)
Total value (line 3 p!'a Ilne n (8)
I hereby certify the above Is We, correct, �9^aNre otASSessor Date signed (monm, dey, yea�
and eomplete.
veriying aaion - signamre ma,aimr �� y9� (�N. �r. r�)
.... . . . .
20 _ pay 20 _ Lesser of 60% of the essessed value of the homestead or 545,000
NoMithsfaMug any otherpiovision, !he sum olNe deduclprts provitled in IC 67.7-12 fo a moW7e home Nat is $
not essassed es mel property or to e menNaCUred home Nat is not assessed es real property may rot axceed
c�,e�nan ) aure wrne moaae r�re or,�eo�tac„�ee n«�re.
�y� � Date signed (month, day, year)
J