Homestead_Adler�.. n
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CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD/SUPPLEMENTALDEDUCTION
Stale Fartn 5473 (R72I609)
P2unbM by ihe Department of Laal Garemment Fi�nce ^
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�� FORM YEAR
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INSTRUCTIONS: See reverse side for filing instrucfions. �
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1(VJe) certify ihat 1(�/re��c/�_� pied as my (our) prindpal
place of residence or am (are) buying the toliowing described real property tor which a Homestead Property Tax SianBard D���reby daimed
under conVact on the date �his applica6on is filed, (tlate of filing): 4�8SON COUNTY q(�p���R
e) own ❑ Am (are) buying under recorded conVact
Am (are) entitled to occupy as a tenant-stockholder of a cooperaGve housing corporation
� Have a benefidal interest in ihe Wst or [he right to occupy the property under the tertns of a quali(ed personal residence Wsl
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Name of da'imant (legal name
e_ e 7-
Sadal Srnuity nirt�bc
Sodal Secunry number of ciaimanYS spouse (last frve tligrts) Drivels licensa / Identlfmation / Other number Issuin9 State
of daimant's spouse (WSt fiw dg2s)
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II drying om m�Vact, Fee Simple rnmers �me
Recordefs oi(xe where mntrac� is recortleE RemN number Page
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�nry Tovmship Tawig tlatriU (rily, rown, fownship)
Parcel num6er Legal dewip' Is e pmpefty in queslion:
' properry ❑ AnnuaOy assessetl mohle home (IC 61.1-7�
•I( arry portim ot ihe resaential swcnire a Ne �arw not e:reeding «�e (7) ace that immeaiatery wrrawMS ihat swaure is used m praduce imm�e, descnbe tne use aM pwtion
of Ne pmpeny uo!¢eE tn poCUce inmme.
� a�-�a -�;�- ao a -odo . ��� -oa�
... . . : . .
Counry TwmshiP Caunry Township.
I hereby certify the above statements are we, correct and complete. � n o aimam n, Q �
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Addreu (numDer antl sheef. dry, state. antl LP cade) /��.?� r O /J ` / !
(P L T
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l.and not exceeding t(one) acre immediatety �:a*":t3' y;s%�%.�:;� �ri`�"� ",' �'$
surtoundin residen6al im rovemenfs. (�) '�.*� Y''1.�. s^.2�' r-i�i<•,
�.°;i::=;r 'y;f•+;z� .
Other land (2) � t•<-_ `;�r.��'�,%Y.' 3'�
Total land (line 1 plus line � (3)
Residential improvemen5 or Annualty �����9 (4� Y�`?��''�- x��"� 3 Y��� �'t r�
Assessed Mobik I Manufacwred Home Garage (g) ..?a-. ��;::,%}� ?��, _�;�P?
�t +�'�5 rs,-„`n�..`f s
3.�.,,,- .a:`' �
Otherimpmvements (C) � :�t.,-.=„-,..�`:
Total improvemenb (line 4 NrougAltne 6j (7)
7otal value (line J pl's Itne 7) (B) '
I hereby certify the above is true, cortect, Sg"an'� °f �B55Of Da:e signed (rtronm, tlay. year7
and complete.
Vaiying amon - SignaW re of PLditnr � Dale signeE (monfh, day, yea�
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20 pay 20 _ Lesser of 60% of �he assessed value ot 1he homestead or $45,000
Ab(wiNStaMirg eny ofherprovision, (ne sum o/ the tletlutG�wis pmvitled in IC 61.1-f 2 to a mo6de frome fhat is S
rrot assessed as real propeny or fo a mawleUUred home Ihat is rof assessed es rea/ pmpaM �Y not exceed
ane-hall (1!1) o1Ne assessed value o! the mobde home ar manutauvred hwne.
59naWre Nfutlitw Dale si9ned (nronfi. day.lea�)