Homestead_Dyehouse(��� CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
� S�a�e Fwm 5473 (R6 / 403)
Prescri6ed by Ihe Department of Local Govemment Finance
INSTRUCTIONS: See revcisc side lorliling insl�uclions.
FORM
HC70
YEAR
��e� � t on the tsl day of March. 20_
I(We occupied as principal place ot residence ihe following described real property ( which a Homestead Property TarCredit is hereby�daime�d:
I(We) owned ❑ Are buying under contract (� r-{ � I,
iHave a benefidal interest in the entity that is liable for ihe propeAy taxes on the property and fhat owns the property o�bu�g under a� nGad'�°�
If buy'u�g om m�Vact, Fee Simpie awnefs name
Remrdels oifice whera conVaq is recordeA
�� �ir����'.+'_+�+"-t"e' i��iT�L�.�a�'�tJ::�-Y��'��it"i�.NT.*
Counry Tamship
Tain9 �'�tritt�iry, tawn, tawn5hiP)
Record number
✓ n ne Lega� description I IS(he property in qu uon:
�� b a� s o-o R�� �o
_ D DertY ❑ Mobile Homo Q C 67.f-n
If any ponion of Ne residenllal sWCture w Me Wnd not meceeding one (1) aae that immediatety wnounds that sWGUre is used to produce income, deurihe Ne use and portion
of Ne property utilhed tn produce iricome.
�
SNTE FOA\I51569 (IUB-10) iREASURER F00.�t TS-IA
MPRO\'FD BY SiATE BOARD Oi ACCOU�TS, ?009 PRESCRIBED BY T3fE DEP.Vti���'i OF LOCAL GO\'ER\lfE.\T FI\A�CE iCb l.l '?-B.1
a^Y� t , � / , , . ' 1 � , � • , • y"��..C�? .
'..J
Indi��iduals and married couples are limited to one homestead standard deduction. As the receipt of this
�'Pduction becomes more beneficial, there is more incentive than ever for homestead fraud. Homestead fraud
causes higher tas bills for all; therefore, HEA 1344-2009 requires taxpayers who receive the homestead
standard deduction to verify that they are eligible to receive the benefit and to pro��ide additional identif��ing
information necessary to allo«� counh' go��ernment to better monitor homestead filings. This information
���ill be kept confidential and can only be accessed by authorized count�� officials. The Department of Local
Government Finance will use this information to create tools that ���ill help county officials eliminate
homestead fraud.
Ta�narer \'ame
1u5tin \1 Drehouse
Pronem�.\ddrcss
i09 \V EMERSO\ ST
PRINCETOAI IN 47670
State Parnl \umber
26-12-07-103-002.6i0-0?8
rµ
Leaal Descrintion:
DEVN E�LG 10 PT
Cou�plete and return to: I�I�IIU�I���u�pl�plQpIIIIImII,II�'uII�II�
GIBSON COUNTY AUDITOR, 101 N MAIN PRINCETON IN d7670
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Ownar 1 First ' MiEale
'� �i� �c/t�� � � eho cu �
MaJVg Adaress (numEer erM aveal, ory, siate a�M 21P cotle)
� $dllf8 i5 y0p@Ry dEdf255
�9 IrV. �'merro,, S�- {��-�vt«� JJ�1 y'1����
Sorial Sevxiry NumOer (last 5 01g1[y DriveYS LicenseJState ID Numbar (last 5 tllglta) wts pNer (please spetity in Pan d belax)
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homesiead standard deduction on this property. Each undersigned also
she may be liable for back taxes and substantial financial penalties.
Ovnn / Sia�:ve Date �
���iY�
SgnaMe
�_ J_
Da:e
//�� /��
//3v/! j
���
>rmanon is true ano correct ana [nat ne or sne is eugioie to receive t
thai, by claiming additional homestead deductions unlawfully, he or
LeSi
JAN 3 0 2013
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