Homestead_Dill�"' L CLAIM FOR HOMESTEAD PROPERTY TAX
_, _,. - STANDARD / SUPPLEMENTAL DEDUCTION
Stata Form 5473 (Ri2 / 6-09)
S �° Pms`sibeE by ihe Depariment of Lo�l Gavertvnent Fi�nce
INSTRUCTIONS: See reverse side for fililg insfiuctions.
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� M'e) cerlify that I(we) ocwpied as my (our) principal
place of residence o m(are) buying the following described real properry fw which a Homestead Pmperty 7a: Standard Deduaion is hereby tlaimed
under mnVad on the date ihis appliralion is filed, (date o7filing):
❑ I(We) own ❑ Am (are) buying under recorded conVact
❑ Am (are) entiUed to occupy as a tenant-stockholder of a cooperative housing corporation
� Have a benefidal interest in the Wst or the right io occupy the property under the terms of a qualified personal residence Wst
(legal neme)
UmeYS Ire:nse I
spouse (lastlrve d9its) I Drivrls Ivxnse / Identification / O�he
ot daimanYs spouse (last (rva dgi6�
If buying om m�Vad, Fae Simple awnefs reme
Recoidefs office where mnVacl is remNed
Counry 7axnship
Pafcel numher
If any portion of Ne resdenfial sWCNre or Ne IaM not exceetl
of Ne PmPertY utiT¢r� to P�ute i�ome.
2b-�a.i�-3o�(•003.
Counry
7ownship
Tarirg diyGyl(rity, town,
IsSUirg
Remd number � Page
�/�/ 7� � p I IS ❑ Rea �in� tion: ❑ MnuaOy assessed rtiObile hOme (IC 67.1-71
�ine (7 ) a�re thai Immadlatety wrraunas that swcwre "s used m ryndure inmme, aesvibe ihe use ana porrion
3(o3-oa8
I hereby certify the above statements are We, correct and complete.
�Addreu(numOeraMSfreet,My,5late,arMLPCOde)
:�_� 4 / 1 -o/
Land
Oltier lantl
Total land (line 1 plus line 2)
acre immediatety
Dwelling
Garage
Other Improvements
Total improvements (Ilne 0 Nrough fine
Total vatue (llne 3 plu line n
I hereby certify the above is hue, cortect,
and complete.
Vaitying aaon - Sgnawre ottwdimr
(�)
(2)
(3)
(4)
(5)
(6)
Counry
XI SignaNre of
�4n
Sig�wre of Pssessor
20 pay 20 Lesser of 60% of the assessed value of the homestead or 545,000
AbfwifhsfaMing any athe�provision, Ne sum ol the deduclions provided in IC G7. f-12 to a mobde home Ihat is 5
nof essassed es reel property oi ro a manufaGUred frome Nal is mt assessed as real proparty may rrof asceetl
one-hall (12) o/the assessed ralue o1 the moEile homa w manNanuied homa.
SigriaWreotNWimr n '
Townslup
Date signe0 (mmM, dey, }sa�
Cay,yea�
Date signetl (monN, day, yea�
STATE FOR1i 95b9 (A]8-10) i'ilEASURER FORM TS-IA
MPROt'FD BY STAiE BOARD OF ACCOUhTS, :009 PRESCRIBED BY T}fE DEPARTAtE.�`i OF LOCN, GO\'ER.\�¢\T FI�AI:CE IC61.1-_"_-8.1
Individuals and married couples are limited to one homestead standard deduction. As the receipt of this
�'aduction becomes more beneficial, there is more incentive t6an ever for homestead fraud. Homestead fraud
causes higher tax bills for all; therefore, HEA 1344-2009 requires taspayers �vho receive the homestead
standard deduction to verify that they are eligible to receive the benefit and to pro��ide additional identifying
information necessary to allo«� county government to better monitor homestead filiugs. This information
�rill be kept confidential and can o�ly be accessed by authorized county� ofGcials. The Department of Local
Government Finance ���ill use this information to create tools that will help county officials eliminate
homestead fraud.
,�, �, � ,�.
Taxnaver Same Pronern� Address Stale Pnrcel �YUmber Le�al Desarinfion:
FIO}'d D Dtll 1909 5 BOULHVARD PL 26-12-18304-003.363-028 BROADLEIGH PARK 88
PRtNCEi'ON IN 47670 �
Camplete mid renrrn 10: Ip�II����u���Q�������l�l�u`II�LII�I��ll�uu
GIBSOY COUNT7' AUDITOR, ]Ol N MAIN PRINCETON IN 47670
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O+mar 1 First . � MiECia Last
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Mailvg MCress (rumiEer arq ztreeL �+�Y. s.e aM ZIP mde) �-cy�e as property aCEress
1- I -
a Bo %uqr l. :��7�'0.�. .�... 7�To
Sotial Senairy NwnEer past 5 Olgits) Dtivels LicensH$ta:e I� ManCer (last 5 Eigits) Slrt� OtMr (please specity in Pari 4 Eelow)
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Spouse Fvs� MiEtlla Last
Mail'uq AGOress (mmber aM sueet, tiry, sWta anE ZIP cotle) ❑ Sama as p�oparty aCtlress
Sadal $eaaity Nianber (last 5 Eigltn) Drivefs LicenselSia:e ID Nunoar (laat 5 tligita) Suu O:tvs (pleau spetity in Part 4 below)
m
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Each undersigned certifies, under penalty of peryury, that the above and foregoing information is lrue and correct and that he or she is eligible to receive the
homestead standard deduGion on this property. Each undersigned also understands that, by claiming additional homestead dedudions untaw(ulty, he or
she may be liable for back taxes and substantial financial penalties.
Owner 1 Signatwe Date Telephone�
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Spouse S Me Data Talaptme
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T AUDITOR