HomeMy WebLinkAboutHomestead_Ellis"'" CLAIM FOR HOMESTEAD PROPERTY TAX
; ._ 4 STANDARD / SUPPLEMENTAL DEDUCTION
State Fortn 5473 (R12 / 6-09)
�a � Prewibed hy lhe Departmenl ol Lo�l Govemmenl France
INSTRUCTIONS: See reverse side for filing inshuctions.
��ORM ;� . YEAR
i � ��
h;;;'{ ] 9 CUIU
1(VJe) ceryrtiN �an I (��f�'�jjr) prindpal
place of resi ence or am (are) buying the following described real property for which a Homestead Pmperty p Sfan ard Dedudion is hereby daimed
under mnVaa on the date this application is filed, (date of filing):
I(We) own ❑ Am (are) buying under recorded conUact
Am (are) enGtled ro occupy as a tenant-stockholder of a cooperative housing wrporetion
� Have a benefidal interesi in ihe Wst or Ihe right to occupy Ne property under ihe tertns of a qualified personal residence Wst
daimam
oi daimant (IaV frve digiLS)
spouse (lasf five dgffi) I Drivers licertse / Itlentlflca�on / Othet number
ol daimanPs spouse (lesl �rre dA7iGCJ
It buying on conirdct, Fee Simple ovmeYS �me
Recorders oftre where mntrac1 is recortle0
-
Counry Tavnship
Pa�cel number
If any portion of Ihe 2sidential swcwre w the WM not exreetling one (1 � a tnat Imr
of �he properry unLZed to podure income. /� / r7'
CJ
- a -�� - 3 G� -�. �
... , ,:
Caunry Township
I hereby certify the above statements are we, cortect and complete.
Pddress (number antl strcet, ary, s�afe, ard LPmde)
,�„ � _ � , _
Land
acre immediauty
Otherland
Total land (line 1 plus line �
Dweliing
Residentlal improvemenis or Mnualty
0.ssessed Mobile 1 Manufacturetl Home Garege
Ofher improvements
Total improvements (line 4 fhrough line 6�
Total value (Ilne 7 phs line 7)
I hereby certify the above is true, cortect,
and complete.
Veitying action - SignaWre o(lwtlitnr
(�)
�Z)
(3)
ia)
(5)
(6)
��)
(8)
Signawre of Assessor
Caunry
of daimant
Record number
Page
ty in ques�on:
pfoperty ❑ MnuaPj assessed mobile home (IC 61. f-
�vmre is used Io proeuce income, desmbe �he use anO portion
20 pay 20 Lesser of 60% of the assessed value ot 1he homestead or $45,000
AbNnlhslaMirg any otherpmvisinn, Ne sum o/ lhe deducGwu pro�idetl in IC 6-1. f-72 ro a moWe fame thaf is g
rot assessed as ieal property or m a manulaUUred hwne Met ic not essessed es reel P�OanY �y �t exceed
ono-haM (72) o! fhe assessetl v21ue of Ne mobde fame ar manu/actured home.
SigriaWre o1PiWitor
7G
Towtahip
Date Signed (rtronth, day, yea�
Oate signe0 (monN, tlay, yea�