Homestead_Villalobos" CLAIM fOR HOMESTEAD PROPEh2TY TAX
�,._ STANDARD / SUPPLEMENTAL DEDUCTION
State Fortn 5073 (R72/6-09)
�' � Prasaibed by ihe Oepartmem ol Local Govemment F�xe
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FORM Y� , .
HC10
H--7 � e R"1 �
INSTRUCTIONS: See raverse side for fifug inshuctions. � � j� �J �/ � f
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� I(we) /� 0 certity that I(we) occupied as my (our) prifuiipai
place of r i nce or am (are) buying ihe following described real property for which a Homes[ead Property Tax StandasA`. uUio�n}:� reby daimed
�er d on the date lhis applipGon is filed, (date of filing): � i�� i° ��T
I(We) own ❑ Am (are) buying under recorded conNact ,(�pIBSQN B�NtY UolTOp
Am (are) enlilled to occupy as a tenant-stockholder of a cooperalive housing corpo2tion
� Have a beneficial interest in the Wst or the right to occupy the properry under the tertns of a qualified personai residence wst
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Nameot �neme) ' .
Sodal
Sodal Seauiry numDer ol dalmant's spouse (lasf five dig'rts) Dnvefs ficense I IdanGfxaOOn / Other number Iswing SYate
� of daimarrt's spause (lasl fiva d!g'rLS)
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II Aryvig om m�tract, Fee Simple wmefs rume
Remrdets of6ce where mntrap is recortleE Remrd number Page
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Caunry iownsnip razing e' �(city, mwn, rownshrp)
( LTI%% '
Parcel number Legal dnsoiP� Is Ne �operty in quation:
- Real ptoperty � MnuaAy assessetl mpyle hdne (IC 61.7-�
tt arry rt d tha restlential stnxa��a or Ne land not exceed'mg me (1) acre Ihai immediately surtau t sWCNra is useE In p�oCUce im.mie, Eesv3p Ne use and portion
ot Ihe nY wTaed to P�uce incoma. . .
� �� - �r-ia -a�� ooi ��� oa� .
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Caunry . Township . Counry TownsNp
1 hereby certify the above statemenis are We, corteG and oomplete. S�"a�� °� `�"'"a"� t, � �
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� Pddress(numDerendstree4�1:s1a:e,aMLPcoCe) .
ro r M� �E iUC�Td �l S.v �
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Land not ezceeding 7(one) acre immediatey '� T,r{ c� _-*-..:-c
surroundin residentialim rovements. (�) �`.�'-�.�-�Z;�������,
Olherlantl (p) � • ' �� y`��m;
Total IanO (line 1 plus line 2) (3)
Dwellin 4 '�`s` `�`� �^�'� �`�'� �4� �
ResidentiallmpmvementsorMnualiy 9 ( � ix% '�' ��"�'F'��K�=�F''-�'
AssesseC MoWk / ManufacwreE Hortre Garege (5) ���r. �s�':�:''-��f �� 3;."..`�.3F.k��s-.^�-..
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Otherimprovemenb (6) �'^`:i-L'�::;::_. f.
,�'+::,.;�;�� �,�.
Total Improvemenb (Ilne 0 Nlough Ilne 6) (7)
Total value Qlne J Pl�s Ilne n (g) .
1 hereby certify the above is hue, cortect, SigriaL�re of Assessor Date signed (rtronN, day, yaa�
and tomplete.
VaifW�9 aUion - SfBnature ofl�udtw Date s'qfu.�tl (rtronN. tlaY Yea�
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20 _ pay 20 _ Lesser of 60% of 1he assessed value of the homestead or $45,000
NolxilhsfaMing enY ��G���. �� at� detlucliartc praindeE in IC &f. f-12 M a mobde home (haf is $
not essessetl es ieal property or ro a manufeclured hcrtie Net a rot assessed es real pmperry may not exceed
one�hal/ (1R) W Ne assessed re/ue o/Ne mo6ile �wne or menufacture0lrome. �
Signature of Nidltw . ' Date signed (monN. day, yxa�