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�'"'" CLAIM FOR HOMESTEAD PROPERTY TAX
, _ STANDARD / SUPPLEMENTAL DEDUCTION
Stata Fortn 5473 (R72 / 6-09)
�° j Prescnbetl by the Department of Local Gwemmenl Friaree
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ws�kuc;i�urvs:�aereverses�aerormuig�nsvucuons. HYK $;9 LU��
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�(yyy) certiry th cpQi' my (our) prindpal
place of re dence or am (are) buying the following desaibed real property tor which a Homestead Prope����Staqd UN7Y�ITOR by daimed
dafeo/filin ���
under ct on the date Uiis applinlion is filed, ( g):
(We) own ❑ Am (are) buying under recorded contract
❑ Am (are) enlitled to occupy as a tenant-stockholder of a cooperetive housing corpo2tion
� Have a benefidal interest in the Wst or Ihe right to occupy the pmperty under the tertns of a qualified personal residence Wst
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ot da'unant (legal
Seariry
)
Sodal Sewriry numGer ot daimant's spouse (WSf five d'gits) Drivefs license I IdenGfiralion I ONer number Issuing S1ate
ol daimam's spouSB (Ias1 frve dyiLS)
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It buying om m�bact, Fee Simple owners rame
RemMefs oRre where convad is rem�ded Record number Pa9e
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�ny TvanshiP Taring �istnri (cify, rown. township)
m �/� Le9al � 'Ption Is Ne DmPenY in W esfim:
r� ��� f 7J • O � Real property ❑ MnuaOy assessed mobile home (IC 6f.1-7)
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If a�ry poNm of Ne residential svucW re or Ne IanO not exceedlrq me (1) ave Ihat immeEiatety wrtaunds Ihat swmre ¢ used tn protluce imm�e, descnbe Ne use and pMion
of tne property utP¢EC m Woduce income. �� �
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Counry Twmship ��b T�'^T�P
I hereby certify the above statemenis are We, corretl and complete. Sgramre � �,
Gress (numDer and street, dry, state, and ZlPOOtle)
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Land not ezceeding 1(one) acre immetliately �„v`-:F''� "�.�y' �-� y.%v-a'`-�<�,��
sunoundin resldentialim rovements. ��� �+�''--=''�"�^-+=�-t'�x1AL��"`=���`--=�.'
Other land (Z) � `.�ri ;��y'��K'�
7otal land (line 1 plus line � (3)
�Y��Y'a`z-'x� �Y'asl r�
Dwelling (4) - Y e#t c.�r?a 2�? �ai-.;'�r�s
Residential improvements or Mnualty �;, .,A > � si . rzy�:,�:
Assessed Mobik I Manufac[ured Home Gara e ��''�^' ,r g"�?'�� '� r�i �"'�:�
9 �5) a..x.,.,.. .��x.. ...�•.>�
,�I: s.:.±;?:ri i e��:._�, •
�F�;1 �"}.'{�` �..rl.
Other improvements (6) . _.,✓.: :'..�; .. : �a
7otal improvements (line s Nraugh line � (7)
Total value (Ilne J pl�a line � (8)
I here6y certi(y ihe above is true, correct, Signawre o/ASSessor Date signed (monN, Uay. yea�
and complete.
Veilying acUm -$i9riaN(e o(Auditw Date signed lrtronN. tlaY. 3��
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20 pay 20 _ Leuer of 60% o( the assessed value of 1he homestead or 545,000
NoRViNSIarMing any otherprovivon. Ihe sumW fhe deducfians prmAdeJ in IC 61.1-f 2 ro e moWle fame Nat is S
not assessed es real pmpeny or fo a rrenu(ectured hwne ihat is rrof essessed as reel properry mey not exceed
one-haH (f2� W Ne arsessed velue a/ fhe rtabile home or manulaUUied home.
sgrumre maw�mr
�ate signed (monM. tlaY. Y��1