Homestead_Potts STATE PIM 53569151 r7L91 TREASURER FORM TS-IA
APPROVED BY STATE BOARD Q ACCOUNTS.%M PRESCRIBED BY 7115 BFPMTA4].T OF LOCAL GOVER:.'ME T FLYAA&£t 6-1.1-11.9.1
IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS
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 tax bills for all; therefore, HEA 1344-2009 requires taxpayers who receive the
homestead standard deduction to verify that they are eligible to receive the benefit and to provide
additional indentifying information necessary to allow county government to better monitor homestead
filings. This information will be kept confidential and can only be accessed by authorized county officials.
The Department of Local Government Finance will use this information to create tools that will help
county officials eliminate homestead fraud.
PART I: PROPERTY INFORMATION
Property Address(number and street,city,state,and ZIP code)
3His 6o S P--LeAn .q, u767o
State Parcel Number
ab - la- H - loo -noo .sgl -ooy
. PART 2:TAXPAYER INFORMATION
05. First �
Cr Middle � Last
Mailing Address(number and street,city,state,and ZIP code) ❑ Same as property address
E
-
��
Spouse First P Middle Last
Mailing Address(Num and street,city,state,and ZIP code) Same as property dress
PART 3:CERTIFICATION
Each undersigned certifies,under penalty of perjury,that the above and foregoing information is true and correct and that he or she is
eligible to receive the homestead standard deduction on this property.Each undersigned also understands that,by claiming additional
homestead deductions unlawfully,he or she may be liable for back taxes and substantial financial penalties.
Owner I Signature Date
•
_
1
• SEP 192013
12112.u -
311 • r
INSTRUCTIONS
•
MvPA-5a
|�N y �2O0G CLAIM FOR HOMESTEAD PR0pE
PROPERTY TAX FORM
CREDIT/STANDARD DEDUCTION
F
State e p wm54r3<no/�os>
[----------1
Prescribed oy the Department m Local Government rinwc"
INSTRUCTIONS: See reverse side for filing instructions.
|0mv 1 o/ March. 2o____
|(^e) occupied ao our principal place of residence the f lowing d cribed real property for which a Homestead Property Tax Credit is hereby claimed:
LJ|KNe>owned [] Are buying under contract
�3Have o beneficial interest in the entity that is liable for the property taxes on the property and that owns the property or is buying under a contract
If buying on contract. Fee Simple cn�nees name
Recorder's office where contract is recorded Record number Page
M
County
Towaiship
County
Toomship
Legal description
Is the propep in qu—esbon:
I
Address (number and street, city state, ZIP code)
ate sig
V C1 Real property Mobile Homo (I.C. 6-1.1-7)
if my portion of the residential structure or the land not exceeding one (1) acre that immanliatety sumoun—dsthat structure is used to produce income. describe the use and portion
of the property utilized to produce income.
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County
Towaiship
County
Toomship
I hereby certify the above statements am true. correct and complete.
Signature of nt
Address (number and street, city state, ZIP code)
ate sig
Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
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Other land
(2)
Total land (line I plus line 2)
(3)
Residential improvements or An ually
Assessed Mobile I Manufactured H
D Efin
we' g
Garage
(4)
(5)
k
Other improvements
(6)
WE—
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(8)
I hereby certify the above is true, correct, and
Signature of Assessor
Date signed
Verifying action - Signature of A�ditor
Date signed
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Lesser of 112 Homestead
valuation or S35.000
Signature of Auditor
ate sig
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