Homestead_Jaquemai�
"'" CLAIM FOR HOMESTEAD PROPERTY TAX
� _ 4 STANDARD / SUPPLEMENTAL DEDUCTION
State Fortn 5473 (R7216-09)
�O J presaibed by Ne Depariment of Loml Govemmenl Friance
INSTRUCTIONS: See reverse side for filing insfruclbns.
o�
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FORM
HC10
YEAR
.
I(We) certify Nat I(we) occupied as my (our) prindpal
place o( r idence or am (are) buyin e fol 'ng desaibed real property for which a Homes[ead Pmperty Taz Standard Deduction is hereby daimed
under co ct on �he dale Ihis appli tion is filed, (date o(filing):
❑ I(We) ovm ❑ Am (are) buying under remrded conVacl
❑ Am (are) entltled to occupy as a fenanFStockholder of a cooperative housing corpora[ion
� Have a beneficial interest in ihe Wst or the right W occupy Ihe property under ihe tertns ot a qualified personal residence Wst
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N o/ daunani (bgal name�
'
name)
$odal $ecunry numDer of tla"unant's spouu (las( five d'gRS) Orivefs license I Identification I ONer number Issui�g State
ot daimam'S spouse (last five dlgits)
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It Wying om m�traa, Fee Simple owneYS �wne �
RemrEefs oBre where mnVaa is rem�ded Record num6er Page
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counry rownshiv raang aisuia (ciN rown, rownsMO)
�p = u b/�� Legal d ' tion Is ihe property in question:
�� (� I�a '• 1 ❑ Real propr,rty ❑ MnuaVy essessed mobile home IIC Gf.1-n
It any porUOn ot Ne residential swcwre w Ne Ia�W not exceedlrg me (1) aae Ihat immeEiately surtaunds chat strucLUe's use0 to pmEUce inwme, descnbe Ne use aM portion
oi tne pmperry utlraed m produce income.
•�• • �: • •
Counry 7ownsl�ip Caunry 7ownship
I here6y certify the above statemenis are We, correU and complete. S" i daimant - �
r ss (number antl stleef. tiry, sfafe. and ZIP cotle)
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Land not exceeding 1(one) acre immediatety �'-.a`:' r*`T�+.;""�' ��-"f. �:E�'"��''
surtoundin residentialim rovements. (�) "ys.==�`���.�ti�—' ���-s n
Y`.�ry.?�� L
ONer lantl (2) a-,^.�� . µ.N `�.;3'-�
eii_.aaN':•.
Total land (line 1 plus line � (3)
-i'-ry.3n , c�,.�,f ..� i y.-.
ResidenuallmprovementsorMnualty ��ling (4) �,;�: � ';F-'�� �r+ ;�s�,,;i
'�`. waE �k� �
Assessed Mobite I ManNachrted Home �-�' ''�+�r'r.��"x e�;cS �-'.
Garzge (5) ,a:.�'� � .i?. <.�� �.{�`.s. �:t_+.,Y:
1 ++'�q:�f "� � -
Otherimprovements (6) f`1 �%,y..� i�
Total improvements (Ilne I through line bj (7)
Total value (Ilne7 p!'s Iine 7) (8)
I hereby certiy the above is [rue, cortect, Sigriature of Assesmr Date signee (rtronth, tlay, year)
and complete.
Vaifyi�9 ac6on - SI9na�re of PLdtor Date signed (rtronlh. daY. Y��)
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20 _ pay 20 Lesser of 60% of Ne assessed value of the homestead or 545,000
Nofuilhsfarvl'ug any otherprovision, Ihe sum o/ Ne tletlucLons povided in IC 6-f. f-12 to e rtab�e home Nat is $
mf assesscd es real property a to e manufectured hane IAa� is m1 essessed es real property may not ezmed
ane-haH (1R) W the assescea rdlue al the rtaGde hortre w manufuUUred home.
� SignaWre of NiEitor �ace 5igneE (rtanth, Eay, yea�