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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Fortn 5473 (R2 / 5-92)
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INSTRUCTIONS: See �everse side !or 7iling instructions. •
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- CERTIFICATION STATEMENT
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1(We) � , , f. ,`�� � certify that on the 1st day of March, 19_
I(VJe) occupied as our principal pl ce of residence the tollowin descnbed real property for which a Homestead Property Tax Credit is hereby claimed:
�V! e) owned ❑ Are buying under contract
❑ Have a beneficial interest in the entity that is liable for the pmperty taxes on the property and that owns the property or is buying under a contraci.
CONTRACTRECORDED
If buying on contract, Fee Simple ownets name
Recorders ottce where contrad is recortled Record number Paqe
PROPERTY DESCRIPTION -
Counry Township Ta�ci tlistrict (ci(y, town, rownship)
Parcel number Legal tlescription �
- � 03-
If any ponion of the residentiai sWUUre or ihe iand not exceeding one (1) acre Nat immediatery surtounds thai swcture is used to produce income, tlescnbe Ne use and portion of
Ne property utilized to D�oduce income.
� PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
CAUnry Township County Township
Signature oi t
•�ereby certity the above statemer.ts are true, cortect and complete.
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AOdress (numberand st2eG ciry, slafe, ZIP code) -7— � ')
803 E� Q�ont�v..o- Pr.�1�.z�O.l 1-fV "l7�%C7
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-FiESIDENTIAL
VALUE VALUE VALUE VALUE
Land not exceeding 1(one) acre immediately (�)
surrounding residential improvements.
Otherland (2)
Total land (line 7 plus line 2) (3)
Dwelling (4)
Resldeniial improvements
Garage (5)
Other improvements (6)
Total improvements (line 4 through line 6) (7)
Total value (line 3 plus line 7) (8)
1 hereby certify the above is irve, cortect, and Signawre of Assesor Date signetl
complete.
Verifying ac6on - Signature ot Auditor . Date signetl
1 STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _
' Lesser of 1/2 Homestead $
, Vatuation or 52,000
Signature of Auditor Date signetl
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SfATE FURM 5�569(2'/]pl TAFASMFR FLRA1 TSI�
ApqtpV�BYSTA� WAPO6ACCQ)YIS.!Iq PqF3CR�m9YT11ECEPAFi�fEVIOFLCCN.CAVFAN�ff.YiiC:MYEIC61.13:-81
Individuals and married couples are limited to one homestead standard deduction. r1s the receipt of this �-
deduction becomes more beneficial, there is more incenti��e than ever for homestead fraud. Homestead
•�fraud causes higher tas bills for all; therefore, HEA 13�d-2009 requires taxpayers ���ho receive the
homestead standard deduction to ��erify that the}� are eligible to �eceive the benefit and to provide
additional indentifi•ing information necessary to allo�v count�� go}�ernment to better monitor homestead
filings. This information will be kept confidential and can only be accessed by authorized county officials.
The Department of Local Government Finance �rill use this information to create tools that �rill help
counri� officials eliminate homestead fraud.
Address (number and street ciry, state, and ZIP code)
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Parcel Number �J
��- la-o� -30 �- Doi. 2.0 3-oa�
GIBSON COUNTy qUp�TpR
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Owner I First �fiddle �� Lazt
Mailing Address (numb r end street, ciry, state, and ZIP code) � Same u properry address
Spouse First � Middle Lazt
Mailin� Address (Number and strcet, city, state, and ZIP mde) � Sarne az properq� address
Social Securip• Number Qazt 5 digitt) Drivers License/S�ate ID Number Qast 5 digiu) Other (please specifi• in Part 4 below)
Sme
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Each undersi�ned certifies, under penalty of perjury, that the above and foregoing information is true and conect and that he or she is
eligible to receive the homes[ead standard deduction on this property. Each undersigned also understands that, by claiming additional
homestead deductions unlawfully, he or she may be liable for back tares and substantial financial penalties.
Owner I Si�at • Da[e Telephone
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Spouse Sienawre Date Telephone
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