Homestead_Reneer (8) STATE FULA 53569 tRi 17-091 TREASURER FORM TS-IA
APPROVED By STATE BOARD OF ACCOUNTS.SM PRESCRIBED BY THE DEPARTMENT OF LOCAL GOVERNMENT FINANCE F 6-I.I-a: I
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,state,and ZIP code)
909 e � 7ZO
State Parcel Number F I L II.� D
-C7 - 1o3 - 0 o o c(0- 0 �LJ`
JAN 3 0 2014
GIBSON COUNTY AUDITOR
PART 2:TAXPAYER INFORMATION
Owner I First Middle /� Last
2)/( -ate v 4__
Mailing Address(number and street,city,state,and ZIP code) %ame as property address
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)
stilt
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
i
INSTRUCTIONS
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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Fortn Sa73 (R2 / S92)
INSTRUCTIONS: See reverse side (or (ling instructions.
FORM
HC10
YEAR
Q 1 �b1i.
CERTIFIC ON STATEMENT
~ I(We) ' certify t on the 1st ay arch,
I(We) occupied as our principal place of residence the following described real property for which a Homestead P e.
❑ I(We) owned ❑ Are buying under coMract - , GIBSON COUNTV qUDITOR -
❑ Have a beneficiaf inierest in the entity that is liable for the properry taxes on the property and that owns ihe property or is buying under a contract.
CONTRACT RECORDED �
If buying on conVact. Fee Simple owners name
Recordets office where conVacl is recorded ' Record number Page
PROPERTY DESCRIPTION
Counry Tovrtuhip Ta�drig Gstria (ciry, town, township)
Parcel number Legal tlescription
- 0 0 -� � �a-�
It any po ion of the resitlential structure or ihe land not exceeding one 1) acre t�at �mmetliarey surrounds that s[ructure is used ro produce income, descnbe the use antl portion of
the property utilizetl ro produce income. � �
PROPERTY OWNED BV CLAIMANT IN OTHER COUNTRIES
County Township , , . Counry TownsNp
Signature ot claimant
iereby certify the above statements are true, correct and wmplete. � �
Atltlress (number and streeG ary, state, ZIP code) �
D�/ �' l.� c,�r St r�� n Gftan 1N �J16 ZU
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD � NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
land not exceeding 1(one) acre immediately (»
sunounding residential improvements.
Other land (2)
Total land (line 7 plus line 2) (3)
Dwelling (4) _
Residential improvements
Garage (5)
Other improvements (6) �
Total improvemenis (line 4 through line 6) (7)
Total value (line 3 plus line 7) (8)
I hereby certify the above is true, cortect, and Signacure of Assesor � Date signea
complete.
Verifying ac6on - Signamre of Autliror Date signed
� , STANDARD DEDUCTION ALLOWANCE
19_ Pay 19
Lesser of 1/2 Homestead S
Valuation or S2,000
Signature of Autlitor Date signetl
�J - 9 -