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E A r
CLAIM FOR HOMESTEAD PROPERTY TAX
3 STANDARD / SUPPLEMENTAL DEDUCTION
7 State Form 5473 (R121609)
l Prescribed by the Department of Loral Govemmem Finance
INSTRUCTIONS: See reverse side for filing instructions.
W 201
CERTIFICATION STATEMENT
I (We) � -certify that I (we) ocwpied as my (our] prindpal
place of residence or am (are) b g the following described real property for which a Homestead Property Tax Standard Deduction is hereby claimed
under contract on the date this application is filed, (date of filing):
❑ 1 (We) own ❑ Am (are) buying under recorded contract
❑ Am (are) endued to occupy as a tenant - stockholder of a cooperative housing corporation
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a qualified personal residence trust
INFORMATION
Name mmant (legal name)
Social
Name of cla'imant's spouse (legal name)))
Soda[ Security number of claimant's spouse (last five digits) Drivers license I Identification I Other number Issuing State
of claimant's spouse (last five dgRs)
CONTRACT ••r r
If buying on rvntract, Fee Simple owners name
Remmers office where contract is recorded Recd number
Page
PROPERTY DESCRIPTION
ry
Township
T i ' ( town rnship)
�)( t
Parcel number
Legal
Is the in question:
� Oip W _
_ ea1 property ❑ Annually assessed mobile home (IC 61.1 -7)
If any portion of the residential structure or the lard not exceeding one (1) ate that immediately summa s t6t structure is used to produce bmmme, describe the use and portion
of the property ubT¢ed to produce Income.
a6 - /3 -!A _ 300 -� /. 6z a -GG�
PROPERTY OWNED BY
County Township County iowmarap
I hereby certify the above statements are true, correct and complete.
S' re of claimant
Pd @ass (n rand city: state, and ZIP code)
lo5ay E s S KI ,� , H SN y7&1P0
ASSESSOR USE ONLY TRUE TAX VALUE ASSESSED VALUE HOMESTEAD NON-RESIDENTIA
AT100%OFTTV
Land not exceeding 1 (one) acre immediatery - r�,t `
(1)
} surroundin residential improvements.
i`'',- T�_4,.�,•,
Other land
(2)_
e
Total land (line 1 plus line 2)
(3)
Dwelling
(4)
c 'ta •. .,
RAW
.u.rt�4
Residential improvements or Annually
Garage
(5)
y, • �`
Assessed Mobile 1 Manufactured Home
Other Improvements
x
Total Improvements (line 4 through line b)
(7)
Total value (line 3 plus line 7)
(8)
1 hereby certify the above is true, correct,
Signature of Assessor
Data signed (month, day, year)
and complete.
Verifying action - Signature of Auditor
Date signed (nmath, day, year)
STANDARD DEDUCTION ALLOWANCE
20 _ pay 20 _ Lesser of 60% of the assessed value of the homestead or $45,000
Notwithstanding any alherpmvision, the sum of the deducboms provided in IC 6-1.1 -12 m a mobile home Nat Is
$
nor assessed as real property w to a manufactured home that a not assessed as met property may not exceed
.
one-half (1R) of the assessed value of the =ode home or manufactured hone.
Signature Signature olNrdito
Date signed (month. day, r)
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