Homestead_DrogichSTATE FOR.N 51569 (R'JS-09)
APPROI'FD B1:STAiE 90ARU OF,ICCOU�TS,'_OD9
TREASURER F00.\I TS-IAI
PRESCRIBED BY TFfr DEPNtTMERi OF LOCAL GO\'FAt.')fE�T FI VASCE IC61.131-9.1
Indi��iduals and married couples are limited to one homestead standard deduction. As the receipt of this
�leduction becomes more beneficial, there is more incentive than ever for homestead fraud. Homestead fraud
� causes higher tas bills for all; therefore, HEA 13a�1-2009 requires taxpayers who receive the homestead
standard deduction to verify that the�� are eligible to receive the benefit and to provide additional identifying
informatioo necessary to allo�v counh� go��ernment to better monitor homestead flings. This information
�vill be kept confidential and can onl�� be accessed by authorized count}� officials. The Department of Local
Government Finance will use this information to create tools that will help count�� officials eliminate
homestead fraud.
Tainarer \ame
Brian Charles Dro�ich
Complete and return !o:
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N�umper (last 5 Eigitz)�
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Last
Each untlerslgnetl certifies, untler penalty of perjury, that the above antl foregoing informatlon Is true antl correci ana thai ne or she is eligible ro recerve tne
homestead standard deduction on this property. Each undersigned also understands thai, by claiming additional homestead deductions unlawfully, he or
she may be liable for back taxes and substantial financial penalties.
Owner 1 Sig(uWre Date Telephone
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CLAIM FOR HOMESTEAD PROPERTY TAX
�, ._- ? STANDARD / SUPPLEMENTAL DEDUCTION
State Fortn 5473 (R72 / 6-09)
�� � Prescribed by the Departmant of Loml Govammern Frence
INSTRUCT70NS: See reverse siCe for filinp inaWCfions
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II(we) certify that�� (J� occuP �si'mQ
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place of residence or am (are) 6uying the foliovring described real pro e fw which a Homestead Property Tax Slandard Dedudion is hereby daimed
under conUad on the date �his applintion is filed, (date ol filing):
❑ I(We) own ❑ Am (are) buying under recorded contract �
❑ Am (are) entilled to occupy as a tenant-stockholder of a cooperative housing corporetion '
� Have a beneficial interest in the Wst or the right to occupy ihe pmperty under the tertns of a qualified personal residence wst
•• • •
Name of imani (lega/ name)
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SodalSenuityrvmberof
SWaI Security numbrl of daimanPs spause (lastlrva dlgGS) Drivefs 6renu / IEentifiption / Olher rvmber Isw'vig State
of daima�rt's spouse Qasi frva dqih) -
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It 6uying m mntraq Fee Simpk ownefs name
RecorCefs o(fice where oontraG is remtleE Record number Page
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Coun TownshiP r� d' ��vy, rown. � �)
Pamsinum6er � Leg esvfD� I Ne �opeftyinquation:
� Real properry ❑ AnnuaOy assessetl rtpGle home (IC Gf. f-7)
I( any W ttre revdential swcWre or Ihe WM nol ex J«e at i �5 at ehuc¢rta is usetl to p�oauce imnrne, tlesWGe the use and poNon
1 O} UIB IIIS¢P1110 P�UC9IIILOIIIB. , M �� "
�� �a -o� ao3-�.�o,r-aa�
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Counry Townsl�iP Counry Tmnsship
I hereby certity the above statements are we, corteG and complete. S' � ot imant � _ �
AEEreu (number and shce4 �; �te, and LPOOOe)
� OS rvSo.�J �-.1 c�TO r C�
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. aurround n� residentiel im) ro ementsdiately �� ) . ����.����'f���`��`�� w
Ot�er lantl � ' (2) r�<�;��'v� ; -.
Total land (line 1 plus line 1) (3)
Owaliing (4) ;'�3'a:2k-:.:' ?��;�^i.�i"�",A�`�'�^'��`
RnldenUal Improvements or Mnualy :k`� '.._.�x�Oi-k.*�5:.�{ r3YL'-gcYt°Ar;?.6KV?
hssessedMobiklManufacturedHome Gara e ��'�` ���`3�J+��
9 �5� ft="°�r a {'x��'+5�.::a.� �.;'*
Other Improvemeriu (6) �F': ����ii���.
Total improvementa (llne 4 Nroug� Ilne 6] (7)
Total value (Ilne 3 pllc line 7) (8)
I hereby certify the above is true, cortect, Signawre of Assessor Date signed (month, tlay, yee�
and completc.
Vai(ying aaon - Sig�w�e of Puditor Date signed (monN, Oey, yeer)
� .... . . . .
� 20 pay 2b Lesser of 60% of Ne assessed value of Ne homestead or $45,000
NMWhstaMbg any oNerpro�.isinn. Ure sum dLre tleQUCbens pro�ided in IC 6f.1-12 to a rtrobde fnme (hat is $
not essaised az real properly w lo e manufacYUred hrn�e (hat'a rot essessed as ieal popeity mgY rwt exceed -
o�e nan ��rz1 wn,e assr.ssea �anre ame moeae nane a���,ra�e,�n r�.
Sig�ature o( N�daw Date sigreE (manN. daY. Y�
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