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CLAIM FOR HOMESTEAD PROPERTY TAX
n ? STANDARD I SUPPLEMENTAL DEDUCTION
State Form 5473 (R12 16.09)
�O Prescribed by the Department of Loral Government France
INSTRUCTIONS: See reverse side for filing instructions.
JUN 2 0 2011
YEAR
OR
CERTIFICATION STATEMENT
I (We) �'�1����p)zrecgi139Ry (our) principal
place of residen or am (are) buying the following described real property for which a Homestead Property Tax Standard Deduction is hereby claimed
under contract on the date this application is filed, (date of filing):
(We) own ❑ Am (are) buying under recorded contract
❑ Am (are) entitled to occupy as a tenant - stockholder of a cooperative housing wrporation
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a qualified personal residence trust
ORMATION CLAIMANT'S INF
Noma of claimant (legal name) � / � ,
2
Social Seaaity number of claimant (
ros 5
Soda] Seauily number of claimant's (ast five digits) Drivers license I Identification I Other number issuing Sate
e,damamaspouse, los vedgts)
/N
�
CONTRACT RECORDED
If buying on contract. Fee Simple cvmers name
Recorders office where contract is recorded
Recortl number Page
PROPERTY DESCRIPTION
County
Township
Taxing distdd 1pt town• township)
Parcel number
Legal description
Is the property in question:
—� - - Z 0 Z
OC,1Q e
property ❑ Annually assessed mobile home (IC 6-1.1-7)
6 any portion of the residential structure or the and not exceeding one (1) acre that Immediately surrounds N duce at structure is used to pro income, describe the use and portion
of the property utiTaed to produce income.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES
County Township County Township
I hereby certify the above statements are true, correct and complete.
Sggnalu f daimant
C
ress (rwmber and street, crIy sate, and7iPcode)
ASSESSOR ONLY TRUE TAX VALUE JASSESSEDVALUE1 HOMESTEAD I NON-RESIDENTIAL
AT 100% OF
2nd exceeding 1 (one) acre Immediatety
oundIn residential improvements.
Other land
(2)
Y. '+F';fi
' Ri ,xyry3• Z;k'
Total land (fine 1 plus line 2)
(3)
Dwelling
(4)
-R..
Residential improvements or Annually
Garage
}.s'N
Assessed Mobia I Manufactured Home
Other improvements
(6)
i:�' „yr•1;s
Total Improvements (line 4 through line b)
(7)
Total value (line 3 plus line 7)
(8)
1 hereby certify the above is true, correct,
Signature of Assessor
Date signed (month, day, year)
and complete.
Verifying action - Signature of Auditor
Date sgned (month, day, year)
STANDARD O I
201 pay 20 L122,11 Lesser of 60% of the assessed value of the homestead or 545,000
Abh,Whstandwg any otnerprovision, the sum of the deductions provided in IC 6-1.1 -12 to a noble home that is
$
not assessed as real property or to a manutartured home that is not assessed as real properly may not exceed
orohad (1/2) of the assessed value of the noble home or manutacbnred tiome.
' n of Aud
Dina sgrad (month, day, )ear)
OR