Homestead_King (2) STATE FORM 53569 QU/)J9) TREASURER FORM TS-IA
APPROVED BY STATE BOARD OF ACCOUNTS.S009 PRESCRIBED BY THE DEPARTMENT CF LOCAL GOVFRNMET FINANCE IC 61.1.22-5.1
IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS
Individuals and married couples are limited to one homestead standard deduction. As the receipt of this
deduction becomes more beneficial, there is more incentive than ever for homestead fraud. Homestead
fraud causes higher tax bills for all; therefore, HEA 1344-2009 requires taxpayers who receive the
homestead standard deduction to verify that they are eligible to receive the benefit and to provide
additional indentifying information necessary to allow county government 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 will use this information to create tools that will help
county officials eliminate homestead fraud.
PART 1: PROPERTY INFORMATION
Property Address(number and street,city te,and ZIP code) ,,,/
/0/a? 0]/_street,
cV- �`-'f2M%/t-C..L / FILED
State Parcel Number
07‘- /02 /dam a010. /699 & 11 JUL 152O15
liseciadr-
GIBSON COUNTY AUDITOR
PART 2:TAXPAYER INFORMATION
Owner First Middle Last
a62. / Jr7n I
Mailing Address(number and street,city,state,and ZIP code) I I Same as pt6p4rty address
C VVVVVV
y-/Y2 C I
Spouse First Middle Last
Mailing Address(Number and street,city,state,and ZIP code) [] Same as property address
Social Security Number(last 5 digits) Driver's License/State ID Number (last 5 digits) Other(please specify in Part 4 below)
State
PART 3:CERTIFICATION
Each undersigned certifies,under penalty of perjury,that the above and foregoing information is true and correct and that he or she is
eligible to receive the homestead standard deduction on this property.Each undersigned also understands that,by claiming additional
homestead deductions unlawfully,he or she may be liable for back taxes and substantial financial penalties.
Owner I Signature Date
CLtXe ideAt l a(/72e,d /rn A -a Ccttf /O/; ,4e,6
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INSTRUCTIONS
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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Fortn 5473 (R2 / S92)
INSTRUCTIONS: See reverse side lor7iling instructions.
FORM YEAR
HC10
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� CERTIFIC FION STATEMENT - �
I(VJe) c� ify that on the 1 st-?ay of March, 19_
i
I(VJe) occupied as our principal place of residence Ne following described r I roperty for which a Home 2rpy� �� redt is he5e6y �med:
❑ I(We) owned ❑ Are buying under contract C'�'SC1� (��� �=!-��"`"�'���
t, �v °UCiT^.'i 1
❑ Have a benefidal interest in the entity that is liable for the property taxes on the properry and that owns the properry or is buying under a contract.
CONTRACT RECORDED
It buying on conVact, Fee Simple owners name
Hecorders office where contract is recorded Recortl number Page
PROPERTY DESCRIPTION
Cou Township Taxing district ry town, law�nsAhip) '
(�C�
Parce numb �� Le9al tlescription ��
It any ponion ol the resi0ential structure or ihe land no[ exceeding one (7) acre that immetliately surtountls ihai swcture is used ro produce income, describe the use and portion of
ihe properry utilizetl to protluce income.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry TownShip Counry TownsNp
ig ture of daimant, i �
ereby certity the above statements are We, wrrect and complete. C j„�1���
tlre55 (numberaM streef, Gry, stafe,�/� eJ �
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ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VAIUE VALUE VALUE
Land not exceeding 1(oneJ acre immediatety (� �
surrounding residenfial improvemenLS.
Otherland (2)
Total land (line 7 plus line 2) (3)
Dwellin9 (4)
Residential improvements
Garage (5)
Other imprwements (6)
Total improvements (line 4 through line 6) (7)
Total value (line 3 plus line 7) (8) '
I hereby certify Ihe above is Irue, correct, and Signamre ol Auesor Dare signetl
complete.
Verifying action - Signature of Auditor Date signed
� STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _
Lesser of 1/2 Homestead S
Valuation or $2,000
SignaWre of Auditw Date signetl