Homestead_Wallisd " CLAIM FOR HOMESTEAD PROPERTY TAX
d n� STANDARD / SUPPLEMENTAL DEDUCTION
�• v StateFOrtn5473(R12/6-09)
S �° Pmuribed by the Department of Laal Govemmenl Finance
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INSTRUCTIONS: See reverse side for filirg ins(ructbns. �
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I (We) �. certify Na�'I��w�Q�ci�d��M�{bIBy�Al�pa�
piace of residence or am (are) uying the following described I propeAy tor which a Homestead Property 7ax Standard OeduUion is hereby daimed
under mnVaA on Ihe date this application is filed, (dafe offiling):
�I (We) own ❑ Am (are) buying under recorded wnVact
Am (are) entltled to occupy as a tenan4stockholder of a cooperative housing corporation
� Have a benefidal interest in the wst or the right to occupy the property under ihe tertns of a qualified personal residence trust
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Name of daimant ( al nama)
Sodal Se�rity nurtber of �
N of daimant's spousa (legal neme)
Social eamry numbu ot daimanfs spouse (last ffve dgds) Drivels Gcense / IErntifiration / Other
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11 Miy"uig om m�trac� Fee Simple ovmers �ame
Remrdets office where mntracl is recordetl Reowd number Page
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Caunry TownsAiP T' district (dty, n, fnwnshiP)
Pa`cel num6er Legal desaiP� is the pmperty in puestion:
l� - l. ��' ' al property ❑ AnnuaDy assessri mobile home (IC 51.1-7)
It any portirn ot Ne resmenllai swclura or ihe IarM mt exceed'ug me (1) aue Ihat imme0iately surtoulMs a[ swcWre is used In p�odure hxane, Eesmbe che use and portion
M
ot Ne pmpe�ty uo!¢ed tn poCUCe ircome.
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Counry iownship Counry 7ownship
I hereby ceNfy the above sfatements are we, correct and complete. Sgnacure of dai � '
Pdtlress(numDeiaM L�l:s(eta,arNLPcQde �1�� � � �M ��
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Land not exceeding 1(one) acre immediatety Yj{Yy.�l� r���...���,s���.��
surtoundin residen6alim rovements. (�� -?=��r-�"=����='y•�="v}�'•
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O�her land �z) . _�k`�:.. _ b.� .. .`.
ToUI land (line 7 plus line i) (3)
. a� �}w t'_a`Z n.� '"u�"r'?y.`'Ev
Dweilin9 (<) xae�cs.}.t,�� �o..��i..,ri c t��
Residential improvements orAnnuaily , . . ��F��,�
Assessed Mohile I Manu(acturetl Home ��3„',., ��4�� 3s�ys} -: -�:�.
Garage (5) tt�'a"4`"S _�w''��F'.�Y»�-z'�•^}
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Other improvements (6) _� k`�.�i�;:3°a'��,'��;^.,x.�:
Total impmvements (line 4 throug� Ilne 6j (7)
Total value (line J plfs line 7) (8)
I hereby certify the above is true, cortect, Sigrawre of Assessor Date signed (monM, eay, yzar)
and complete.
Vaifyvig adion - Sigriayra M fwtlitw ' Daie SfBrietl (rtronN. tlaY. Y��)
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20 pay 20 _ Lesser of 60% of the assessed value ot ihe homestead or $45,000
NaNrithsfandirg eny ofherproNSion, [he sum ol Ne detluctions provided in IC 6-1.142 to a mob�e home (hat is 5
mt assessed as real property or ro a menuleUUrea hwne tha/ is no( essessed es real propelly meY �� esceed
one-hatl (12) o/the assessed value o/1he mobde home ar manufarturetl hartre.
SignaWre of Puditor Dete signed (mmN, tlay, yea�
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