Homestead_Schmidt (5) STATE FpW$356flt'I]!K) TREASUR}]t RIBMTSIA
STATETD BY STATE BOAR)OF S.]C•N PRESCRIBED BY THE DEPARTMENT 6 LOCAL GOVERNMENT FINANCE re-LI-33-9.1
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 I: PROPERTY INFORMATION
Property Address(number and street,city,state,and ZIP code)
/DD 7 f' iiA ? S 9 92-e a-hat A; 'Y 7,6 7a.
State Parcel Number
z -70%? —dS - 30 7 doe 07- 6'(--267 FILED ._
JAN 14 2015
.,
PART 2:TAXPAYER INFORMATION _ _ _ _
Owner I First Middle Last
r/5/04\01- L _pc A in id t
Mailing Address(number and street,city,state,and ZIP code) cg Same as property address
I PART 3:CERTIFICATION • I
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 ignature Date
PART 4:ADDITIONAL INFORMATION • -
v 1
I
. 1
INSTRUCTIONS
} CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
/ Sute Fwm 5473 (RB / 1-03)
Prescnbed by the DeDartment of Lacal Govemment Finance
INSTRUCTIONS: See reverse side !or Iiling insfmcfions.
FORM YEAR
HC10
9 k� ,' � ��`9 TTT
�(N�e) , q .
(or which a Homestead Property Tac Credit is fiereby daimed:
� I(We) owned ❑ Are buying under wntracf �^�, / /(/��,1�/ ///� /n/
, Have a benefidal interest in ihe en6ry that is liable (or ihe property taxes on Ihe property and ihat owns the, prope �rry ;is buying�under�"a wntraU.
If buyin9 on coniract, Fee Simple ownefs narne
Recortlers olfice where conVact (s rewrded
County To.mship
Parcel number Leg e:
�/ - - �ti (,
If any poAion af Na resitlentlal sWcWre w the Wnd not
of Ne OroDerty utili=e0 tn produce income.
Recard number � Page
town, lownshipj
/� ^� I Is the P�Pe�Y �n question:
x
'� u r�,�eal Droperty ❑ Mobila Homo (I.C. 67.1-�
o�e (1) aae that immediatety surrounds that ctura is used to D�duce income, describe the use and portion
�;�?'i��'���,�.-�"y-t�d,;?;j.S�i.-�.��»s'��EPROP.ERTY,OWNED:,BY� CLAIMIANT; IN�OTHER"COUIJTIES,*Y.,,;�.�`..�+,i�n.`�:�a-��,-;��'t_�F.j'S��
County Tavnship County Tavnship
I hereby certify �he above slatemenls are W e, conect and complete. Si ture ot ciaimant
Addreu (num6er aM sheet, ciry, sfafe, ZIP code)
�j �s�- �AS ESS�D�R�SEONLYS.��� .�' �RUEsTAX� ASSESSEDVALUE �HOMESTEAD���pNON�tESIDEN�IAL �h
�F . #,T�y���spa.w,.��;���� i�ae...�iVAL'11E��� : ATj100� OF'TTV� �,VALUE� �� ��s •. VALUE� -�...'�3�`u�
e�.._.- �.Edbiai'...��.��.�•Y-.�-.
Land not exceeding 1(one) aae immediately �"y,��" '�'�-��3� a'�'�
surtoundingresidentlalimprovements. (�� �����'S',�'.�`��� a3`�`.
Other land (y) r`� '�... J,�� .
�t�
7ota1 land (line 7 plus line 2) (g� �
� � � ���� �
Dwelling (4) �.���������
Residantiel improvemenLa or Mnuaily �y� � tF
AssessedMadblMerpifacWredHome Gara9e (5) �?�-t..��•. :� �'��v����
,.���°� -�,�
Oiher improvements (6) ��'�',y�t,'�/^�`. ��, +
�� .�r�16+9L ..>.�k'
Tdal improvements (line 4 fhrough line 6) (7)
Tdal value (line 3 phs line � (g�
I hereby certify the above is We, cotred, and Signamre o(ASSessar oate signea
complete.
Verifying aclion - Sig�tura of Fwdimr Date signed
�'����c��`'a'�%�`�.'��s£���.�^.�-'-�,�STANDARU'.DEDUCTION'ALLOWANCE;t+v�-r`' a�k..`�3,�..#.'`.€�'��-�'�4���«'�t�.�i``�"'�e?'x_=_�-�x..
20_Pay20_
Lesser of 1l2 Homestead
Vauanon w f35.000
5
Sgnature otPUditw - Date signed