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CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD/SUPPLEMENTAL DEDUCTION
State Fortn 5473 (R721609)
Prescribetl by Ne Department of Loml GovamrtreM Frenca
FORM
HC10
YEAR
INSTRUCTIONS: See revarse side fw Airg instrucfions ' ��
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I (we) � certiry that �op�uPier���Y (our) prindpal
place of residence or am (are) buying the following de ' real property for which a Homestead Property 7ax Standard Deduclion is hereby daimed
under conVact on the da[e Ihis applira6on is filed, (dafe o/filing): C�����
❑ I(We) own ❑ Am (are) buying under recorded conVact
❑ Am (are) enlilled to occupy as a tenant-stockholder ot a cooperative housing corporetion GIBSON COUNTY AUDITOR
� Have a benefidal interest in the Wst or the right to occupy the pmperty under the tertns of a qualified personal residence Wsl
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Nam of da' al name)
Social Sewriry
Sodal Security rnim6v of tlaimanYS spouse (� � d9�) Orimels Ikense I Mmtifxation I ONer number Issuug a�=
- ot UaMam's spouse (lasl five dgits) -
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II buying on contracl, Fee Simple ownrls rume
Recordefs afice where mntraG is remrde0 Remd numbu Page
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�my Twmsttip Te�dng d'¢trid (uty, wn, In ip
m.nJ numher �7 � Leqal EesaiPtion Is th 7�PenY in qu�tion:
�p� �/� �oZ�� • '��. �G�VenY ❑ MnuaOyassessedmad'lahome(IC&1.1-7)
If eny poNm of the resfden�al sWCWre or Ne IaM nol exreedirg rne (1 � arre �hat immediatety surtou�s Uwt strucWre is usad to yoduce 4�wme, desaibe Ihe use and poRion
of Ne pmperry unTaed to produre inmme. .
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County Township Caunry Towr�sNp
I hereby certity ihe above statemenis are true, corted and complete. Signamr daimant ` �
Pdaress (numDer and sGeet, riry, steta, eM zrPtode) .
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Land not ezceeding t(one) acro ImmediateN :��'�„s y�� t; �
nurroundin residentialim rovements. (�) _€: .�"�3+�� ��ve��_'
��x'.�s.�+��� � .a., �i
Other land (2) �i:"�+.�;,s'�,.:.:.�a�.z...;
Tatal land (line 1 plus line � (3)
ResldentiallmprovemenborMnualty �����9 (4) "'������¢���'��
/lssessed Mobile 1 ManWactured Homa '���-"'� �°3a'"-��iR,'+'s�.?'��`
Ga2ge 5 '�a ?.�° „4`�� y �.>�°Cx
( J K:�,.,J_:2.�-. ><a�S�._,-,
�,��µ ��.
Other Improveme� (6) ��,�-��".?ji r;'S'$,F„�::
Total Improvemen� (line 0 through Ilne 67 (7)
Toql value (llne J plus line 7) (8)
I hereby ceRity the above is true, cortect, Signawre of Assessor Dare signed (month, day, yea�
and complete.
Vaih�ing actim - S5ru�re of Puditor Date signed (monN. OaY. Ka�
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20 pay 20 _ Lesser of 60% of the assessed value of the homestead or $45,000
NawilASfaMUg eny aNer pmvivon, Ne sum o/the deduclia�s provitletl in IC 61.1-12 ta a mo6Ae home ihat is $
rrot escessed as real property w la e rrenuhctuied home (ha� is Inf assessed as leal property mey not exmed ,
o H( ) d Ne ssessed rdl W Ne mo6de hwne wm2nu18GU�Btl hrnie.
S" ria l ' Date signed (e)pn -y, y�g(y — l/.
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