Homestead_Etolen (4)Gibson Counry Auditor
101 N Main
PRINCETON IN 47670
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IndiriduaL. and rtu;rieJ couplec arc limi�ed to onc homeynJ �lzndtN Jcdunioa As ihe recctip� of �his dedurtion bcconw_
mure benencial, thrrr i. morr i�rcentne dnn r�rr for homnrcal fiaW. Ilom veaJ fraud causes hi�her Ia� bill> fw all: therefine.
HEA 1 i17-2pQ9 requim u�paren who mccire �he hanes�ced standard AeJuciion w veriiy �hat tM1ey are elieide to reaene �he
benefit an1 ro p`w�ide a�klitioiul identiiyinc infomutwn �a�s�rv to allow counp� gmemmem to Y.t¢r monitw Mm�ead
filir��. This in(omuliai w�iil M Aryv crntiAeNiai and �n nnly M aatesnl 6}' awMr'vrA county ofliai�ls_ The IXpanmem o(
Lucal Gwcrnnem PivM< ��ill u.e this intortnation ro cr<a:e 4vls that wfll h;Ip cpmn• official> diminmc homcsrcaJ fraud.
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� 'Taxparer Name Prupem� Address
Etolen, Gary A/
APR 7 �O�Q `1U6 \YtlmnAVL
Prinreton 1\ -07670
120$ —Yn
Gary A/ Etolen �IBB6N'� UN�� ifi@F
906 Wilson Ave State Parcel Number Leyal Description
Princeton IN 47670-3134
I' II "I II I'll II11'll"I'"I III II'1I'I11I x 26-12-OS-200-003.465-028 01903465-OODIKEENLGTRACT71
This form MUST be returned to County Auditor's ofFice.
Please do NOT send this form back with your tax payment to the county treasurer.
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ON�ncr I First Middlc Last
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�e Addmss (uumber end ->t�ceL city, sm[e, and ZIP code) �$ame as pmpeM addrts:
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Social Sccuriry Numbcr (lan i dieits) Driver's Licrnx/Statc ID Nmnber Qu� 5 digits) Oihcr (pleasc specify in Pan 4 below)
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Each undersigned certifies, under penalty of pepury, that the above and foregoing infortnation is we and wrrect and that he or she is elieible to
receive the homestead standard deduction on this property. Fach undersicned also understands that, by claiming additional homestead deductions
unlaw�fvlly, he o: she may be liable for back taxes and substantial financial penahies.
O�.'�rcr I Si�meW`e �> Da�c Tcicphonc
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