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CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
STANDARD /SUPPLEMENTAL DEDUCTION FORM
State Forth 5473 (R13112-09)
t Prescribed by the Department of Local Government Finance
INSTRUCTIONS: See reverse We for fifug instructions.
I (We) —certify that I ) o s ) p deal
of residence or am (are) buying the following described real property for which a Homestead Property Tax Stan a u on Is a imed
,place
V +er ntract on the date this application is filed, (date of filing). I (We): NOV 2 9 2011
Own ❑ Am (are) buying under recorded contract
❑ Am (are) entitled to occupy as a tenant - stockholder of a cooperative housing corporation C.'J.
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a qualified personal residence Ws
❑ Am (are) the shareholder, partner or member of the entity that owns the property. GIBSON COUNTY AUDITOR
•• e
Name of t Qegal name)
social Security Mind"
Drivers license I Identification I Other n ben
of claimant (last fire dgifs)
Issuing State
Name of daima it's spouse (legal name)
Social Security number of flai nears spouse (last fire digits) Driver's firanse I Identification I Other number issuing State
of ctabnams spouse (last five dgds)
• ••�
If buying on contract, Fee Simple owners name
Recorders office where contract is recorded Record number
Page
Township Taxirug distritl (city, town. township)
County
Parcel number
Legal tlescriPtion
H the property in question:
❑ Real property ❑ Annually assessed mobile tome (IC e- 1.1 -7)
If any portion of the residential structure or the land not exceeding one (1) acre that immediately surrounds that structure is used to produce income, describe the use and portion
of the property, utilized to produce Income.
W VY\
County Township County Township
hereby certify the above statements are We, correct and complete.
sgnatue a ai n'
Address in and street, city, at and ZIP coda)
3 '�
• r • r
Land not exceeding 1 (one) acre immediately - x ?- '•',,.? "�5"• �' ' `T`
surrounding residential Improvements. (1)
r
Other land
(2)
Total land (line 1 plus line 2)
(3)
Dwelling
Residential Improvements or Annually
Assessed Mobile I Manufactured Home
(4)
ci4f'jr '�'• €.
Garage
(5)-';m
n
xa`='"�
Other improvements
(6)F
Total improvements (line 4 through Ilne 6)
(7)
Total "too (line 3 plus Jim 7)
(8)
1 hereby certify the above is true, correct,
Signature of Assessor
Date signed (month, day, year)
and complete.
Verifying action - Signature of Auditor
,e� Date signed ( , day, year)
,�
1 • uU�-+'-' W �
r • • r r r
20 pay 20 Lasser of 60% of the assessed value of the homestead or $45,000
Notwithstanding any ether provision, da sum of the deductions provided in IC 6-1.1 -12 to a mobile fame that is $
not assessed as real property or to a manufactured tame that is not assessed as reel property may not exceed
one•haff (1R) of the assessed value of the mobile lame or manufactured tome.
Signature of Auditor
Date signed (month, day, year)