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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Fortn 5473 (R2 / S92)
FORM
HC10
YEAR
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�' CERTIFICATION STATEMENT ,� _
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I(We) ��. � certi at on the 1st d���a,,,���y of March, 19_
I(We) occupied as our principal place o residence the lowing described real properry tor which a Homestead operty Tax C/edipl_�hereby aimQd:
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❑ I(We) owned ❑ Are buying under contract . � /- �
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❑ Have a beneficial interesi in the entity that is Iiabie for the property taxes on Ihe pmperty and that owns the property or �s buying undei-a�contract.
�CONTRACTRECORDED �
II �uying on canVact, Fee Simple owners name �
Recorders office where contract is recorded - Record number Page
PROPERTY DESCRIPTION
Caunry , Township T' district (dry, rown, rown hip)
Pamel number [egal descnption
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If any poNOn of the residential sWCWre or Ihe lantl noi exceeding one (1) acre Nat immetliatey surtounds that structure is used to produce income, descn6e Ne use and portion of
Ne praperry uulized to pro0uce income.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
County Township Counry Township
Signature aimant
.iereby certify the above statements are true, cortect and complete.
AdAress (number and street, ciry, state, ZIP code)
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ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VAIUE VALUE VALUE
Land not exceeding 1(one) acre immediately (�)
surrounding resideniial improvements.
Otherland (2)
Total Iand Qine t plus line 2) (3)
Dwelling (4)
Residential improvements
Garage (5) .
Other improvements (6) .
Total improvements (line 4 through line 6) (7) .
Total value (line 3 plus line 7) (8)
I hereby certity Ihe above is lrue, Correct, and Signature of Assesor Date signed
complete.
Verilying action - Sgnature of Auditor � Dare signetl
• STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _ .
Lesser of 1/2 Homestead S
Valuation or 52,000
Signature of Autlitor Date signed
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Gibson County Auditor
101 N Main
PRINCETON IN 47670
1600
SIAiE f01{M!!H IP_ ( YNI
.1��RP'F➢ BY t� �iE BMRDK/!'.p�'IR.9v
IndiriJuals and nu:riN coupks are Iimiltd io nnc home�tead AandaN AMuninn..4s the �tteipt of this JNurtion becmres
morc beneficiaL �here is morc incrntne tlun rcer (or homrs;eul fnud. Homo'ttaA f2ud nuses higher_�aa bills (or all: thnefore.
HEA 13�ti-?IXW requ'urs mipaien w'ho «eeive ihc hanesteaJ smndard JNunion w.erifr ttut they are <IiciMe �o mcene the
benefit anJ tu p�a'iJr a�kliiional iJentii�'ine infurmatiun �xcezs�ry ro allm,� counn gmrmment to baver mumror humrnead
lilin�. This infarma�ion will be Aep1 mnlidrn�ial anA can only h� aace�sJ M1y aWhnmd ronnlr o(Tcislti.'I'he Ikpanment nf
I_ocal Gm'<rrvnem RmM<.�ill u.c this iniomwcion to arcatt iwls that �vfll h:Ip cwnn� officials eliminatc Mmmstcal fraud.
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T:�spavrr Nnmr Prnpertc Addretis
Fortner, Clayborn A
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Claybom A Fortner
116 Olive Dr
PRINCETON IN 47670.3454
�i�n��ui����n�in���uin��n�n�����n�n�ni��i��nu��i�
I 16 Olive DR
Princcton IN 476J0
State Parcel Yumber Leeal Descriotian �
26-12-18-304-002.642-028 01&02642-00 ROSS PIACE 7
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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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Owoer 1 First MidNe / LaSi
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•�g Address (nunber and �vm, ciry, staec, and ZIP code) �m< as propcm addrcs�
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$ociai
Spou;e First Middlc Lva
11� R�E
Mailine Addrcss (Nwnber and svice� city, state. and "LIP code) � S�une u pmprny adJies�
Social Security Number jlact 5 digi�s) Dnvers License/Sta[c ID Nwnber (las� 5 digits) Oeher (plrase apecify in Patt 4 below�)
sms
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Fach undersismed cenifies, under penalry of perjury�, that the above and foregoing infortnxtion is We and wrrect and that he or she is elieible to
receive the homesiead standard deduction on this property. Each undersiened al>o understands that, by claiming additional homestead deductions
unlawfully, he or she may be liable (or back taxes and substanrial financial penalties.
Owncr I $igna4uc Datc Tdephonc �
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Spousc Sip�anirc � � patc Tclephonc
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