Homestead_Burchell STATE FORM MO(1t1 B-10) TRFASUAFA FORM TS-IA
APPROVED BY STATE HOARDOF RECOUNTS.IDN PRESCRIBE BY THE DEPARTMENT OF LOCAI.rASTA'MENT FINANCE IC 61.1-214.1
f
Co EilIPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS
j 11. M,,FaI a=i Individuals and married couples are limited to one homestead standard deduction.As the receipt of this deduction becomes
P 1F`°""' ,I 6'`-� more beneficial,there is more incentive than ever for homestead fraud.Homestead fraud causes higher tax bills for all;therefore,
NOV HEA 1344-2009 requires taxpayers who receive the homestead standard deduction to verify that they are eligible to receive the
II N1 6 2011 benefit and to provide additional identifying information necessary to allow county government to better monitor homestead
Y filings.This information will be kept confidential and can only be accessed by authorized county officials.The Devitt-vent of
Local Government Finance will use this information to create tools that will help county officials eliminate homestead fraud.
• C'�'ff‘Ts..-.. PART 1: PROPERTY INFORMATION
— GIBSON COUNTY AUDITOR Taxpayer Name Location Address
• . Burchell, Larry Lee/Julia Anna
Dimmett
713 W FOREST PARK DR
PRINCETON IN 47670
1349
1100111 DI 01 D0101111010 11110111110110111111101011 ii :111.10 IILarry L Burchell
P O Box 701
OWENSVILLE IN 47665-0701
ll"'ii ii 111'IrrtIltFllllrl�IlrllllllIlll"Iltllrllllltllrllll State Parcel Number Legal Description
26-11-01-304-000.286-028 PT SW 1-2-11 .21 AC
This form MUST be returned to County Auditor's office.
Please do NOT send this form back with your tax payment to the county treasurer.
Tip 'iSR�-..1&\PAIL.H ENFORNIM1lO\
I First Middle --- -� - Last - —
Mailing Address( umber and street,city, •-- :i d ZIP code) a q .M e as property address f b
eD. B04 ID( , ..�e2� S _'� "e- Duasur ) QI �-4V -1(, it
Social Security Number(last 5 digits) �RnvET S Lice nsefState ID Ntmiber (last 5 digits) Other(please specify in Part 4 below)
5-13 Ia I o Ig I Ai snu
- 1' First Middle •st
P %
Mailing Address(Number and street,city,state,and ZIP code) ❑ Same as property address
i ►� IRS ,$3J1\
t . S6k 1e l.SI �4it ° (
Social Security Number(last 5 digits) Driver's Licenne/State ID Number (last 5 digits) Other(please specify in Pan 4 below)
tHI 1,I6I -1l b cIR I -iI '4Ic ThQ so,r,
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
tmlawfully,he or she may be liable for back taxes and substantial financial penalties.
Owner I Signature Date
1
O'YLOw/ 7/.? X.IR- 4 A -
FOflM MC 70 1979
Prescri0ea By State Board o� 7a. CammiSSioner5
To Be FileO in Duplica�e
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT FOR YEAR 19�� d�
SEE �K FOR FILING INSTRUCTIONS Q�9� �D�g�'�O
� , � . .
�,(We) °f �� certify that on the 1st day of
✓larch, 19 I, (We) occupied a o principal place of residence the following described real property for
which a Homestead Property Tax Credit is hereby being claimed:
I, (We) ❑ owned
❑ are buying under contract
❑ have a beneficial inte est in the taxpayer
Property Description i e —,` County �� Township
Taxing District {6iFy, Town, �awcship):�e�
Parcel Number .
If buying on contract: Owners name �'� "`"o'e °w"ef�
or legal description shown on tax statement:
.
T �S �1�� �-a-ii , a� �,
Contract recorded in Recorders Office - Record
If any portion of the residential structure or the land, not exceeding one (1) acre that immediately surrounds that
structure is used to produce income, describe the use and portion of the property utilized to produce income
Any other counties in which individual owns or is buying real property:
i hereby certify the above statement is true: correct and complete.
�n //1 /% . t _ � , . � .�, .. �
County Township
7 l�
' Individual either owns or is buying under a contract that provides he is to pay the property taxes
on the residence, or has a beneficial interest in the taxpayer.
- FOR ASSESSOR'S USE ONLY
Land not exceeding 1�ne) �re i�medi�iely �
surrounding residential improvements
Other �and JUL � 0 1979.
Total Land
Residential Improveme� � ���ti�k�,elling
, p AUDITORGarage
Totai
Other Improvements
T�' � Improvements - Line (6) plus (7) equals (8)
i�by certify the above,�s true. correct. and complete.
OI A55Q55p�
True Cash
Value
(�) � (o D
(z) — ° —
Assessed
Valuation
� O
_o—
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.- ����i �.v .a/
: � /��%%
.
: —• - � — '
__- � ` ' j�����j/i
_ � i. D
: L� - 0����0000
-� a
a
Homestead
Valuation
S O
- ACTION BY AUDITOR -
Approved:�f�-• v�-S�¢.S.Ch� Date:�G - �9
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