Homestead_DuguidCLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
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Pieavibed ny aie Depa6ne'rt of Lom� Gouen.nera Fa,an�
INSTRUCTIONS: See iaverse side Rv filing uutructions.
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�(VYe) � certi�Y tha4'6(�`�7'st da7(bf M��aQ�. 20_
I(We) pied as aa P�aP� P� of ratidence the 'rg descnbed real fa whidi a Haneste��gr(y��'eoY daimed:
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1( paCOn otihe residelaial s4umue oI Me land nal one (1) aoe tlat inme�ey amaur� tl� �w�Uae is used b P�� iimme� deacnbe IM iae arW paUon
d �A"(�0 Oo protlice rt�mne.
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County Twnship Gounty Tawnship
I hereby ceAi(y the above 5ta�ls are true, oorract and conplete.
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�- � rAS3ES30RUSEONLY ' .� ,'7�i`��I '�' TFSJE,TAX � ASS�SSmVALUE Fh�IffSTEADi" �^`Y �NO!litESIDH�IT1Al����'
j i�' y M1.� t h:: $��H rl?�'' i�� r VALUE �. -.AT 100X OF ATIV .}�' � VAI.UE ua a.. ¢+*...'k.� ��:r,tit,i::.VALUE,r.. F'� r�
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Land not esceeding 1(one) aae irmiema�ly "-�y��iti���yd����1�,s.tf,+�'�'4 �i'2� ° w, r>
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Tdal value (!cre 3 pds 6ne n �g)
I fleeeby certiy tlie above is We. mrreti. ard Serr�.e of Aeaeswr Data s9+ed
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y` 's; �,':,P..iSDWDARD'D�UCTION'{1hLOYVAMCEx �r�i.�'.!N ,:?'&,� ..�,a::':�tY.. ,:c,:?i�W�.i�„�t0f,�._.
20 _ Pay 20 _
Lesser of 12 Hwrestead
V�uation or 535�000 f
sig�hre ora,�m. � se�
STATE FOMI 53569 (WI&10) i1tF.�5URFA F02N TS-IA
APPROt'ED B\' SfATE BOAAD OF ACCOU�TS. 2009 PRESCIUBFD BY i}[E DEPART�fE�'! OF IACqL GO\'ER\'���T Fl�A�CE ICbI.�;"-8.1
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Iudividuals aud married couples are limited to one homestead standard deduction. As the receipt of this
�+eduction becomes more beneficial, there is more incenti��e than ever for homestead fraud. Homestead fraud
�causes higher tax bills for all; therefore, HEA 13442009 requires taxpayers who receive the homestead
standard deduction to verify that they are eligible to receive the benefit and to provide additional identifying
information necessary to allow couuty government to better monitor homestead filings. This information
will be kept confidential and can onl}` be accessed by authorized county officials. The Department of Local
Go��ernment Finance will use this information to create tools that will help county officials eliminate
homestead fraud. '
Ta�oavrr Name
lama $cott Du�uid
Complete and retunr to:
ow„e� �
Satial
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Each undersigned certifies, under penalty of perjury, that the above and foregoing infortnation is We and correU and that he or she is eligible to receive i
homestead standard deduCion on this property. Each undersigned also understands that, by daiming additional homestead deduaions unlawfulry, he or
she may be liable for back taxes and substantial (nancial penalties.
O+ner t Si�a�ue Da;e Telaptv�e
s�o���a
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GIBSON COUNTY AU
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