Homestead_York srATE FORM 53569(RE/]VI) TREASURER FORM TS-IA
APPROVED BY STATE BOARD OF ACCOUNTS.?W9 PRESCRIBED BY THE DEPARTMENT CF LOCAL GOVERNMENT FCUNtE IC 61.1"-LI
IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS
Individuals and married couples are limited to one homestead standard deduction. As the receipt of this
deduction becomes more beneficial, there is more incentive than ever for homestead fraud. Homestead
fraud causes higher tax bills for all; therefore, HEA 1344-2009 requires taxpayers who receive the
homestead standard deduction to verify that they are eligible to receive the benefit and to provide
additional'indentifying information necessary to allow county government to better monitor homestead
filings. This information will be kept confidential and can only be accessed by authorized county officials.
The Department of Local Government Finance will use this information to create tools that will help
county officials eliminate homestead fraud.
PART 1: PROPERTY INFORMATION
Property Address(number and street,city,state,and ZIP code)
� `i 6 / .d /BOO Da�Ca� d (± v ? 66o
State Parcel Number L^
d &-/y- /9-joy - 000 . o67 - co 6
PART 2:TAXPAYER INFORMATION •
OxnerliCCy First Middle Last
yjn/n -
Mailing Address(number and street,city,state,and ZIP code) Same as property address
Spouse First Middle Last
Mailing Address(Number and street,city,state,and ZIP code) ❑ Same as property address
Social Security Number(last S digits) Driver's License/State ID Number (last S digits) Other(please specify in Part 4 below)
Sate
PART 3:CERTIFICATION
Each undersigned certifies,under penalty of perjury,that the above and foregoing information is true and correct and that he or she is
eligible to receive the homestead standard deduction on this property. Each undersigned also understands that,by claiming additional
homestead deductions unlawfully,he or she may be liable for back taxes and substantial financial penalties.
Owner I • ature Date
Spouse igna Date Telephone
( ) I
PART 4: ADDITIONAL INFORMATION
• . 1tJ '
APR 0 7 71114
INSTRUCTIONS
CLAIM FOR HOMESTEAD PROPERTY TAX FORM
CREDITISTANDARD DEDUCTION
State Farm 5473 (86 14.03) F
prescribed by the Department of Laced Government Finance
INSTRUCTIONS, See navenite atla, IbrMing km&ucbormL
I (We) certify tha
oMs)6,4;�M,rch, 20
1 (We) occupied as our pq�ipal piece of((jsidence the following describjema y erty T I
�perty for which a Homestead Pro erty T Credit
❑ ](We) owned ❑ Are buying under contract (318sot4 coug"t aimed:
Wh Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns the property or is buying under a contract.
If buying on contract, Fee Simple owners name I
Recorder's office where contract is recorded Record number Page
County Township Taunq district (city, town, township)
6-7- 1 1 (11W
Parcel number Legal Ion Is the property in question:
-- 5a "IM or, I
00 3 km R6 AY" 7, property ❑ Mobile Home (IC. 6-1.1-7)
If any portion of the residential structure or theAanb not exw,4d!r;g one (1) im that im, iet�e*surrounds that structure is used to prod" inane. describe the use and portion
of the property utilized to produce incoma. 71
Aolvq- la
County Township County Township
I hereby certify the above statements are true, correct and complete. S, ature of claimant
_&dress (number and street, city, state, Zip code)
ASSESSOR�USE ONLY
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Land not exceeding 1 (one) acre immediately
0)
surrounding residential improvements.
Other land
(2)
A k`
Total land (line 1 plus line 2)
(3)
Dwelling
(4)
Residential Improvements or Annuany
UM
Amettsed Mobile /Manufactured Horne
Garage
(5)
ag
Other improvements
(6)
Total improvements (fine 4 through line 6)
(7)
Total value (line 3 plus line 7)
(8)
I hereby certify the above is true, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature Of AddlMr
Date signed
-rAN6ARE 'DEDUCTIOWALLOWANCE
eF'MY., =Wgs I-
20 Pay 20_
Lesser of 112 Homestead
Valuabon or 535.000 $
Signature of Auditor Date signed