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CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD / SUPPLEMENTAL DEDUCTION
State Fwm 5473 (R72 / 6O9)
�O � Preuribed by �he DeOartmenl ot Local Govemmem Frence
FORM YE�
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INSTRUCTIONS: See reverse side for filLg insNations. ' �
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I(we) rti(ptt�l as my (our) prindpal
place of residence w am ( buying Ihe tollowing desc+ib I ropeAy fw which a Homestead Property Tax Standa '�hereby daimed
under mniract on the date this applicalion is filed, �— J'r'Z �O % (date o/filing): �7 COUN �Y��11 D1
❑ I(We) own �, Am (are) huying under recorded convact «� �' '� _ �,Q /7
❑ Am (are) enGOed to occupy as a tenant-stockholder of a cooperative housing corporation ��Qp,� C�J3� �/'�
� Have a beneficial interest in the wst or the right to occupy the pmperty under the terms o qualified personal residence Wst
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Name of �nt al name) . '
Sodal Seacrty nmbg d nl (fast M.e d'g3t) s ficense I Identifiratlon / ONtt number Issu"mg State
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II buyfng om m�tract, Fee Simpk oariers'ume � �
Remrdefs ofGCe whe contract is remNed Remd number Page
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Counry Tamshi7 Tariig dtstrict (�. wn. town5hi0)
PartUnumber Legald 'p' IsNepropertyinqu�tian:
' Rnal pmprny � MmiaOy assessed rtm60e home (IC &1.7-7)
If any portion d Ue residential sW W�e or the IaM not exreeC'ug ane (1) aae ihat Mmediatety wrto s ihat strucwre is usad to pfoduce hxune, Eescnbe tlx use aM portion
ot Ihe propeny ubf¢ed ta produce Nmme. �
-a6 �a-o7-yo�3- ce3,�58-�aF� -
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Counry Township Caunly Tmmship
I hereby certify ihe above stetements are W e, corred and complete. 5� nature ot aai m
PdEress (num6er and stieet. tlry, afete, aM code) '
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Land not e:ceeding 1(one) acre Immediatety �r�s s` �,��"�'��""-�
surroundin resitlential im rovemen�. -��) ' -£ ����`'�'ri' � --.�: �
k �. �:-x .
ONer lantl (2) � , ��'��F
. �.�`:: �:�%.,.�ti
Total land (line 1 plus line 2) (3)
ResidentiallmprovemenisorMnualty �Ilin9 (4) `�*��''��5��"'�'r�,5�����*�
.�f- t? .�F32T•?
Assessed Mohik / Manufac4rted Home ��k �"" 3 i�'� ��3?". �
Garege (5) �r';{wrz}x.i.`-'.�.rc: v
'k"+`.`"'7`��S'�:'n _
�+: Y�. L A!'^'L fY c� C�. .
Other im rovemenb 6 ' �� �" ffi'•: r:�
P ( ) v?;4_'..���!"fitivSVrrX
7ota1 Improvemen� (llne I NrougA line 67 (!)
7otal value (ftne 3 pl�c line � (B)
I hereby certity ihe above is true, cortecl, Sigriature af Assassor Date signetl (rtwnfh, day, yea�
and wmplete. �
Veifying acUm - Si9naNre of �tor Date signed (monN. dzY. Y��)
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20 Pay 20 _ Lesser of 60% of the assessed value of ihe homestead or 545,000
NMVilhsfarMUg eny olherprovision. Ne sum ol Me deductions provifed in IC &7.7-72 fo a mobde Irome Nat ls $
rroi assese0 es reel property a(o e rrenufaCUred hwne Nat is rot assessed es roal property may not exceed
oneJ�aH (72) dNe essessed ve/ue dlhe rtaede hwnc ar manu(actured homa.
Signauue d Audlior Date signed (manN. OaY. Y��