Homestead_FoleyCLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
Stata Form 5473 (R6I4-03)
Presaibed by Me Departmetri of Lasl Gwemment Finance
INS7RUCTIONS: See reversa side 1or filing inshucfions.
FORM � YEAR
HC10 �
J��
i�we� Vi certify that on the 1st day ot March, 20
I(We) occupied as our princip place oi residence the following d ribed real property (or which a Homeste`�ad PyropeAy�Ta3c��Credit is hereby daimed:
�"i6� �! V
❑ I(We) owned ❑ Are buying under contracl �TpR
`Have a benefidal interest in ihe en6 that is liable (or Ne ro e taxes on the ro e �g�q�pr�U,NTY. AUD 9
h' P P rty p p Ay and fhat ro ny or is bu in under a wnVaU.
If buymg om m�iracl, Fee Simple owners name
Remrders olfice where contraq is remrded
a ��.�'{�..s`"��ii_'�—._�'�'s-��`'�'s.a"����
Counry � Tavnship
Legal
H any portion of Ne residenUal sWCWre w 1he land not
ot the property util¢ed to produce income.
County
To.vnship
RecorA number � Pa9e
district (ciry, mwn, (ownship)
1he property in queslion:
❑ Real property ❑ Mablle Homo (I.C. 61. f-7)
one �7 ) aae t�at immediatety sunounds Nat swqure is used W produce incoma, describe the use antl portbn
I hereby certify the above statements are We, wrtect and complele.
sveet,
STATE FOIIM S1569 (RIIB-10) TItEASURER FON.�I TS� IA
MPRO\'ED Bl' SfAiE BOARD OF ACCOU�TS, _'009 PRE$CIUBED BY T}1E DEPARTTfE\T OF LOCAL GO�'ER\'1fE\T Fl�0.\CE ICbl.l"-8.1
"�s�: 1 , � , , , . ' 1 1 , I � , � tle.,�-a �..
.1= �.E. �:+tti4; .
Indi��iduals and married couples are limited to one homestead standard deduction. As the receipt of this
�eduction becomes more beneficial, there is more incentive than ever for 6omestead fraud. Homestead fraud
* causes higher tax bills for all; therefore, HEA 1344-2009 requires taxpay�ers 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 county governmeut to better monitor homestead filings. This information
���ill be kept confidential and can only be accessed by authorized county officials. The Department of Local
Go��ernmeut Finance will use this information to create tools that will help count}� officials eliminate
homestead fraud.
7'ainarer Name
Christopher M Foky
Cor.�ple�e mzd re1!!tn tn:
O.mcr 1
�N��S tol��d�P.'
' �
MiGdie Lest
Same es wwertY �ess
sw. � o:nar (Wease soacCY in aan a oebw)
�.rtifies, under penalty of perjury, tbat ihe above and foregoing information is true and correG and that he or she is eligible to receive �
deduction on this property. �ach undersi9ned also understands that, by claiming additional homestead deductions unlawfully, he or
�.back taxes and sybstanGal financial penaities.
',� / / / / / // Data TeleoOOna
Date
%/- 27- �z
( �'�
Telephp�e
� �
NOV 2 9 2012