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"'" CLAIM FOR HOMESTEAD PROPERTY TAX
� STANDARD/SUPPLEMENTALDEDUCTION
S� Y State Fwm 5473 (R72 / 6-09)
�� � Prescnbed by ihe DepartmeM of Loml Gavemment Frence
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SEP 2 2p11
YEAR
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c(. GIBSn
� (We) cEtG�j �ta��(��'o&i1�l30�iY (our) prindDei
place of residence r am ( re) buying the following described real property for which a Homestead Pmperty Tax Standard DeduUion is hereby daimed
under conVaG on Ne date �his appl'rotion is filed, (dafe o/filing):
�1 (We) own ❑ Am (are) buying under recorded conVact
Am (are) entiLed [o occupy as a tenanasrockholder ot a cooperaUve housing corporetion
� Have a beneficial interesi in the Wst or the right to occupy the property under Ne terms of a qualified personal residence Wst
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Name o urwri (lagal name)
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Soda� Searily rumibu '
LGrr�
Sadal Seanfj m�mC� of daimanfs
o,��MS=�������,�d�,
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If buyinB on contract, Fce Simple owneYS lume '
RecoNefs ot&s where mnVad is remded Remd number Page
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Counry TownshiC . T' Q�Gjffi: fown, iP)
ParceJ number al 'ption Is �he proPerty in question:
/ � poperly ❑ MnuaOy assessed mohle home (IC 6f. f-n
If any portim ot Ua resitlential swcwra tt Ne IafM nol exoeetling pce (i � a that immeAiateJy surtourids Ihat structure is used ro produm Ncome, desmbe the use and parGOn
of Ne pmperty utif¢eE to V�uca income. �
a�-la-�g-3ati-a� S7�-�ag
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CownY 7ownshiP Couny 7amshi0 � /
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I hereby cerlify the above statemenis are W e, corteu arM complete. Sig�u�ure (' almant �
A4Aress (num6ei and slmet, tlfy, sfat . antl ZI
z3 � 7
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lantl not e:ceeding t(one) acre immediauy �=-+�� ��°��a "�+ ^-
1 �,�.�� �a r�'3.�°'� ".� ��
surtoundin re5ldential im mvements. � ) ��,,...�tf^�,[.a.,'v'�?s��„���r.Tq*�
Olher lantl � (2) r�s'�����
Total land (line 1 plus line � (3)
Dwelling (4) ' ;"�''�q'��-`�-� �-a,� s"K'
Residentlal improvementv or Mnualty �-"�xn .f.- ' �'4��'.�'s'-?'::.-.t�
P�ssessedMObiklManufactumdHome Gara e �="�is'W ?��s� -t�`s,�{�b
9 (5� E :'� iJ're���;�2� >.r?r�.°;F'.+�'�'
Other improveme�rts (6) '+'�c�-�ti� '•°� '�%'�'
t �,.� �'���....
Total impmvemenb (line I Nrough llne � (7)
7otal value (Me 3 phc line 7) (8) _
I hereby certify the abova is we, cortect, Sigriature otASSessor pate sign¢d (nionth, tlay, yea�
and complete.
Vaiyio9 actim - S5natu2 of FuQtw 6ate s9�ed (mm1h. daY. Y<e�
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20 _ pay 20 Lesser of 60% of the assessed value of the homestead or E45,OW .
NohWLGWrd"ag eny atherpro�ision. Ihe sum ol Ne dedudw�c providetl in IC &f. f-12 M a mobde Ipme Nat is $
nof essessed es real poperty or ro a menufactwed hwne Nef a not assessedes real properly may rpt exceed
oneheH (f2) o/Ne assessad value o! Ne mobde hwrm w manutactuied hwne.
Signature o1 �tw Dete signed (month, tlay, yea�