Homestead_Christmas (7)� Y CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
/ State Fortn 5473 (R6 / 403)
� - Prescribed by l�e DeparUnen� of Local Govemmenl Finance
INSTRUCTIONS: See revcrse side lor liling inslmcGons.
FORM
HC10
YEAR
� iWe) certify that on the 1st day of March, 20_
I(We) �ed as our principal place ot residence the (ollowing described real property for which a Homestead Prope� �dil is here�Jby.��a
I(We) ovmed ❑!ve buying under contrect g--{
, Have a benefidal interest in Ihe entl Nat is Gable (or the ro e taxes on Ne ro e y � .
ry p p rry p p rty and ihal owns the pmperty or is buyin�def'a'�in
Caunty
7armship
Tating
Is Ne
v � i v . .. .� � �.ti Y.� ✓ � ( — „c —1 v I ��_
I( any portion of the residential sW cture w the Wnd not exceeding one (1) aae that immetliatey surrounds ihat
ot the pruperty utiaed lo produce inwme.
Counly
I hereby ceAify fhe above statements are W e, corted and complete.
street, ctiy, stafe, ZIP code)
Land not exceeding 1(one) aue immedialety
surrounding residen6al improvements.
Other land
Tdal land (line 7 plus line 2)
Dwelling
Rasidential Improvements or Mnually
Assessed Alohib / Manulac�red Hame Ga2ge
Other impravements
Tdal improvements (line 4 through line 6)
TUaI value (line 3 plus line n
I hereby certi(y ihe above is we, corred, and
complete.
Vaifying action - Signature o(ALtlitor
I�1
IZ)
(3)
(4)
(5)
(6)
I�)
IB)
SignaNre ol Asussor
of
in quesUon:
property ❑ Mobile Homo (I.C. 6f.7-n
ture �s used b produce income, describa Ne use and portbn
signed
Date signed
STATE FORM _<]569 (It3B-10) TRFASURER FORA1 T$-IA
MPRO\'EO BY SrATE BOARD OF ACCOU�TS, �009 PRFS�RIBEO B\' THE DEPMTME�T OF LOCAL CAt'ER.\'MEYI' Fl�p,\CE If61.1�2.-8.1
� , � , , , � 1 � � 1 � , �
Individuals and married couples are limited to one homestead standard deductio�. As the receipt of this
deduction becomes more benefcial, there is more incentive than e��er for homestead fraud. Homestead fraud
�auses higher tas bills for all; therefore, HEA 1344-2009 requires taspayers ���ho receive the homestead �
dard deduction to verify that they are eligible to receive the benefit and to provide additional identifying
information necessary to allow county� go��ernment to better monitor homestead Flings. T6is iuformation
��vill.be kept confidential and can only be accessed, by�'authorized couoh' officials. The Departmeut�of Local
Go��ernment Finance «�ill use thisinformation to create tools that will help'counh� officials eliminate
' - - � - homestead fraud. � � _
r�,��.�...�
Richard L Church
r���n aaa�H:
328 S RACE ST
PRINCETON M �7670
Slve Parcel Yumbrr
26-12-07-301-00 L533-028
Leeal DescriuKon�
PT SE 7-2-10.1 I AC
Complete and return to: ���p��00�pQQ�Q�mm�
ia u
GIBSON COLJiVTP AUDITOR. 1C1 N b1AL��i PRINCETON IiV 47670
1• 1
B^�1' - "'�J`/�oG,fG Flrst Mieele
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caui u�iuersiyneo wmnes, unoer penain o� p=r7ury, ma� me aoove ano roregoing inrortnanon is �rue ana covect ana mac ne or sn? is eu9ioie �o recerve �
homestead sfandard deduction on this property. Each undersigned also undersfands that, by Gaiming additional homestead deductions unlawFully, he or
she may be liable for back taxes and substantial finandal penaltles. �
Ovma t Si�a:ure ��e Tdeptwne
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