HomeMy WebLinkAboutHomestead_SamsCLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR
CREDIT /STANDARD DEDUCTION HC10
•� J State Form 5473 (R5I 10-01) W (�
Prescribed by the Department of Local Government Finance
INSTRUCTIONS: See reverse side for riling instructions.
I Me) ( W�& Y loemQL,6q F cB}tifyUort°tt(t ,W' o`f March. 20
I (We) occupied as our principal place of residencie following described real property for which a HomesTaffrntyluutedit is hereby claimed:
LkI (We) owned ❑ Are buying under contract
iHave a beneficial interest in the entity that is liable for the property taxes on the property and theyowns the propert6! is buyM uglier a contract
If buying on contract, Fee Simple owners name
contract is recorded
Record number I Page
. P, ROP. ERTY: DESCRIP. TIDN P
�'„ ��, Yy�°. � .�!�t „s?+'w��,'-5'�;.?``.�.�''u
County
Township
Taxing Intl ity, town, township)
P I mbar
L ga escripli n
is the property in ton
W
—Z — R
I Real property ❑ Mobile Homo (I.C. 61.1 -7)
If any portion of the residential structure or the land not exceeding one (1) acre that immedial imuunlds that structure is used to produce income, describe the use and portion
of the property utilized to produce income. y
o?G - /5/-i 9 -tea a - e5z�f/. a.ja
AS ESSOR'USE ON Y -. ' lip.
< j
County
Township
County Township
I hereby certify the above statements are true, correct and complete.
Signature of claimagr -j A/� Q �
/V
ddress (number and street, oily, state, ZIP code)
%O%MVALSUTEAD+
AS ESSOR'USE ON Y -. ' lip.
< j
S
SESED VUE
i�TUETAX
40WRESIDENTAL '
U S
E jjh:
- ATi100 *OFTTV x
%O%MVALSUTEAD+
Land not exceeding 1 (one) acre immediately
nxwra
surrounding residential improvements.
Other land
wgtg
-1`T` °3
Total land (line I plus line 2)
(3)
Dwelling
(4)d�-
.0 I'�3iA`.'t r�F aS'•R.�dp £ 'ct#
•^'tero}57_,�,
Residential improvements
Garage
.ii�n� 4�
�
Other improvements
(6)
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(6)
1 hereby certify the above is true, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
20_Pay 20_
Lesser of 1/2 Homestead
Valuation or $6,000
fi -T -1
Dale signed