Homestead_Dillard� CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
� Sute form 5473 (R6 / 4-03)
Presaibed by the DeDartment of Local Govemmenl Finance
INSTRUCTIONS: See �evcise sidc !or Iilinq insVUr.lions.
I (We)
I(We) occupied as our principal place oi residence lhe (ollowing describ d real properry for which a
❑ I(We) owned ❑ Fve buying under contract �
, Have a benefidal interest in ihe enfity that is liable (or ihe property tazes on Ihe property and th�
If buying on conVaq, Fee Simple ownefs name
conirad is recorded
TamshiD
rating aisvict (dry, rown,
FORM
HC10
� y�
� � .
YEAR
_ certify that on the 7st day of March, 20_
omestead Properry;7ac Credil is hereby daimed:
1.-: t , - ' '
GIBSOn QU��'�' -_ _..
owns the property or is buying under a wntraU.
Record number � Page
Parcel um(j��[r /'� "�[`�y� Legal des ion Is ihe prop�My in quesGon:
� / / —(/� QJ W ������� � � Real property ❑ Mobile Homo (LG 67.1-�
H any ponion of Ne residential sWaure n tha land not esceedinp one (1) ace that immediatety wrtounds that s cwre is used b pmduce income. desui6e the use and portbn
ot the prapeny uLlaed to produce irKOme.
�F ��'�A E� USE N Y����H� �TRUE:T�'�� ASSESSED VALUE s�°�HOMESTEAD�'` `� aNONSRESfDE�U1L � �
£�'- ' ,,.��„�.�le�,�r.�W.�.is�'�(�� ��'�VI�IUE��a� �AT�100/aAF�'T.N� � �VALUE� �F,a���VALUE y;�x?�,�
Land not exceeding 1(one) aae immediatety ?'��""� ��,�"-.,,g�' '£��?',� �?�
surrounding residentlal improvemenls. (�) ` �c.���`�"��£;,�'�.,,",�.�'.
Other land -!`�� $�
(Z) rr� �, e-" _
��� ��
Totat land (line 1 plus line 2) (3)
Dwelling (4) "�`� }"{�.,������hj
ResidentielimprovementsorMnually �`������� `�p s`.�'"�
Assessed Modle / ManufacLired Hane Garage (g) �` ��„�` `�`'sr5,� t:u"�' �-
��w'�n3�a'�. s {�
. • :�i���^`�
Otherimprovements (6) ����� � k
� � ' �.��-..�5= �
�.3.
TUaI improvements (line 4 fhrough line 6) �7)
Tdal value (line 3 plcs line � (g� -
I hereby certi(y Ufe above is We, coned, and Signawre of Assessor Date signed
complele.
Verifyi� actbn - Sigrmtura oflwdiWr Dale signeA
STATE iOR.N S1569 (R'J8�09) TRF.�SURER FOR.N TSIAI
MPRO�DBY ST.•TE BOARD OF dCCOU\T5. _'OW PRFSCRIBED BY T}fE DEPARTME�T OF LOC.V. GOVERN?1E�T Fl\ANCE IC61.1-32-A.1
' , � , / 0 . , 1 � , 1 � , �
Indi��iduals and married couples are limited to one homestead standard deduction. As the receipt of this
deductioo becomes more beneficial, there is more incenti��e than e��er for homestead fraud. Homestead fraud
•auses higher tar bills for all; therefore, HEA 1344-2099 requires taspayers �r�ho receive the homestead
standard deduction to ��erify that they are eligible to receive the benetit and to provide additional identifying
information necessar�� to allo�v county government to better monitor homestead filings. This information
�r•ill be kept confideutial and can only be accessed by authorized counh� officials. The Department of Local
Go��ernment Fiaance will use this information to create tools that will help counh� officials eliminate
homestead fraud.
.�� �� �
Tuw�tr \amt Pracerb' Addrcss Slale Parttl \umber Le_al Dncrintian:
Emest R Dillard ]c � 4 Box 3�z x 26-I I-12301-003.085-028 019-03085-00 BROADVIEN 25
Princetan IN 47670 ('
Complete and return !o: �
CIBSON COUNTY AUDITOR 101 \�IAIN PRINCETON IN 47670
�' �
Owner 1 First % � MitlEle "� / Las!
�^ ��c :/z �✓t, � �4. el �✓
� IN<1 � �
Ma�ng nCOress (�� � sa�t ory, state aM ZIP wtle)
❑ Same az qopttty a00ress
� Q y i.3 � o�./ �< <�,� c��� zP r�. �
sodai sea,nry wmec �msi s e�a�¢1 Pivets Licmx State ID N�rtber (last 5 EI9��) � ome. (p�� sceay �o Pan a oeio.�
�'" % � .
Spouse First htiENe lan
�-,,.5.� �t ��s � � C C� �,�
Mai6ng AdEress (�wwrtEer aM sveeL ory. s�a�e anE ZIP cotle) ,
Same as pmpeny zOEress
/ o Y ,�. o < �/ � , t ,;�, �C�.� � � ,�,- . .
Sodai Sewriry Nurrter �mst s mpi�s� pivefs Licenu State ID NurtEer (hst 5 Elgltz) suro oNa �pinase speaty in Pan a eelow)
� -
Each undersigned certifies, under penalry of peryury, thai the above and foregoing information is We and correct and that he or she is eligible to receive the
homestead standard deduction on this property. Each undersigned also understands that, by Gaiming additional homestead deductions unlawfulry, he or
she may be liable for back tazes and substantial finandal penalties.
Qmert Signariue Date Telephme
C/' ���� %`L �-"�� `Z� Z ° l� � . ?'/
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