Homestead_SelfCLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
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Preeabed by Ihe Daper6nent aF Lo�l Gouameil Franm
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SEP 1 1 2001
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I(VYe) om�pied as aa pr"vidpal plxe of ' the to8owirg desrnbed real popeAy tar whirl� tead Property Tmc Cre�t is hereby daimed:
�) owned ❑ Are Wryug urda mntrad r
Have a ber�efidal 'v�terest m the entily Mffi is liade fior C�e property tmces m ihe propeAy and Mat ams Cie poperty or is Giying under a contract.
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d Ilre prope�ty Wi�d b ptoduce e�mr're.
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I hereby certiy tlie ahove is We. cartea. and �B�e o(�v Dam s'gied
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1�iyng aaWn - Si�mUae ol M�dtur Dete nipned
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20 _ Pay 20 _
Lesser of 12 Ho�#ead
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ARNOVFDBY SfATEB6V�Cf ARWYI'S.9N q(FSCR�mBT TFIE RYMT.�'\'I� LCfAL GOVEA.N�\T FL�AlKE Cbl.l � 81
Individuals and married couples are limited to one homestead standard deduction. As the receipt of this '
�duction becomes more beneficial, there is more incenti��e than ever for homestead fraud. Homestead
fraud causes higher tas bills for all; therefore, HEA 1344-2009 requires taspayers who receive the
homestead standard deduction to verify that the}� are eligible to receive the benefit and to provide
additional indentif}�ing information necessar�� to allo�r• county government to better monitor homestead
filings. This information ���ill be kept confidential and can only be accessed b}' authorized county officials.
The Department of Local Government Finaoce will use this information to create tools that ���ill help
count�� officials eliminate homestead fraud.
erry Address (number and sveeS city, state, and ZIP code)
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Parcel�umber SEP 2 3 2013
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COUNTY AUDITOR
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U�ner I First Middle Lazt
/L Q/i.?�� vY_ ����i�a�C.m�-
Mailing Address (number and street, city, state, and ZIP code) Same az properry address
S�Securiry \umber Qut 5 digi¢) Driccrs Licensel5mte ID Number Qast 5 dieits) Other (pleaze speci(y in Pan 4 below)
Spouse First Middle Last
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Afailing Address (Number and sveet, ciry�, statt, and ZIP code) � Sarne at pmperty address
Sceial Sceuriry� Number Qut 5 digiu) Drivcrs License/State ID Number (laze 5 digits) Olher (pleaze spccify in Part 4 below)
5ae
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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 taKes and substantial financial penalties.
Oxner I S' mure Dare Telephone
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Spouse Sie�uture py�� Telephone
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