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"'" C IM FOR HOMESTEAD PROPERTY TAX
!-_ ; TANDARD/SUPPLEMENTAL DEDUCTION
State Fortn 5473 (R72 / 609)
�° � Prescribed by Ne �epaNneni ol Lo�l Gwemmem France
INSTRUCTIONS: See reverse side !o� filing inslmctions.
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I(We) certiy� iah1at I(we) �� our) pri�pal
place of residence or a( e urng the following descri6ed real property tor which a Homestead Property Taz����i9n' rehv.daimed
under contract on ihe dat his applipEon is filed, (dafe o/(ling): ���R
❑ I(We) own ❑ Am (are) buying under remrded mnVact
❑ Am (are) enlilled [o occupy as a tenanFStockholder of a cooperetive housing corporation
� Have a benefidal interest in ihe Wst or the right to occupy ihe property under the tertns of a qualified personal residence Wst
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Name o nt ( al name)
So�l Seanity rua�ba af (6sf frs d.g.is) D�ivefs ficense
Sodal Securi number of daimant's spouse (last five dgrts) OriveYS tirense I Wenti�xation /
Y�
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If buying om m�Vact, Fee Simple ownefs name
RecoNefs ofice where mnvaa is remrtled Remrd numher Page
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�n Tovmship Ta�dng d�s (c� ro ipn�
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P!,y�� number //� /�_���^� Le9al tles�clription Is in queslion: '
OC�/�"'�I^(VI,iZ,��p! � p� I �IP�PertY ❑Annuay'aSUssPAmodlehome(1C6f.7-7)
�tt any portion ot Ne msideniial sWCWre or [he land not exreedifg one (1) aae that imme0iatety wrtountls that strumre a usaC tn pmduce iMane, Eescribe ihe use an0 portion
of the p�operty uti�¢ed m proEUCe inmme.
I
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Caunry Township Caunry Tamship
i hereby certify ihe above ststements are We, correct and comple[e. �`� °� ��� /`
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drew (numEer and sbeet,cA�ty /slafe, antl LP e) � �(� ��� �
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Land not e:ueding 7(one) acre immediately -� �a w,."-+'ri. `�`�'`?� �`f�,�?�"'�'
surtoundin resitlential im rovements. ��� p=;-t. �'��+-�=" `����''
._f��.'�-`"::�.zs' �� 3�i?':i,.�
Other land (2) -,.`n�b':.��,t�'„
Total land (line 1 plus line t� (3)
�tr' 4� C ��- Ks' '
ResidentlallmprovementaorMnualty �����9 �4) . `'� ��'����� �� ��`'['�`
Assrssed Mobile 1 Manu(actured Hwne �"„� i 4��� � Y�� FY�,K�TM.r`'.
GareBa (5) aa:.� _ �'1 .. � ��.,.. .ar_e.: ;:
'�� 5.:� ""tk �„
O[her imOrovements (6) _n_,,,.__,,,s. .. ,
Tofal Impmvements (line d througn line � (7)
Total value (Ilne 3 pAs I(ne 7) (B)
I hereby certify ihe above is true, cortect, SigraWra ofAssessar Date signed (mmM, tlay, ysar)
and complete.
Vailyi� acGOn - SigfaNie o(AUAicor Date si8ned (rtronfh. daY. YT��)
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20 pay 20 _ Lesser o( 60% ot the assessed value of the homestead or $45,000
NolwilhslsrM4g any olher provision, fhe sum o1 the dedurlians provided in IC G7.1-7Y �o a mobIIe froma Ihaf is $
rmt assessed as real poperty w fo a manNactured hrnie Ihat is rpf assessed as real properry may rwt erceed
one-hatl(12J d ri�e assa55ed value of Ne mobie Mme a manutarturetl home.
synawre m a,altor � �ste sip�m (rrronlh. dar, r��