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s' CLAIWIF OR HOMESTEAD PROPERTY TAX FORM
YEAR
CREDIT/STANDARD DEDUCTION HC10
9 State Form 5473 (R614-03)
prescribed by the Department of Local Government Finance
INSTRUCTIONS: See reverse side for riling instructions.
+CERTIFICATIONISTATEMENT,,-',= ?-
I (we) LLdL Vfy It 0 th. 11
Property 1
riv a I
I (We) occupied as our principal place of residence the following de ad real property for which a Homestead Property axL
SV
f I (We) owned ❑ Are buying under contract MAY 1 0 2005
aave 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.
IiUUN I KAU 1-Kt:GUKL)F0 ,,, - —, .: -1
If buying on contrscL Fee Simple owner's name I
Recorders office where contract Is recorded Record number peas I
lslt�-Vi VN�Pkiqt4'41 P RO P E RTWOWN E Di BY.0 LAIMANT. I WOTH E R" C 0 U NTI ES SVFM4Z-
-PROPERTY-DESCRIRT100t
County
Township
_knNONIRES16ENT
TALASSESSOR
Taxing district (city. to", township)
Parcel number
V(0_t4)1_30jr_00
Wp��
I Is the property in question:
[N,fk 1 0 Real property ❑ Mobile Home (I.C. 6-1.1-7)
If any portion of the residential structure or the land not exceeding we (1) acre
of the Property Wiled to produce income.
fist immetiately sumotinds ffiat structure is used to produce Income, describe the use and portion
lslt�-Vi VN�Pkiqt4'41 P RO P E RTWOWN E Di BY.0 LAIMANT. I WOTH E R" C 0 U NTI ES SVFM4Z-
County
I Township
County . . 7�_nshllp
_knNONIRES16ENT
TALASSESSOR
I hereby certify the above statements are true, correct and complete.
Signature of cfaiment
.41se (number and stree4 city, state, ZIP code)
' USEjONLX�sn
A_S_SESSE,DVA_L_ U' E'
- K
HOMESTEAD
_knNONIRES16ENT
TALASSESSOR
,g
INE,
VALUE
Signature of Auditor
Date signed
6:vo-ox
Land not exceeding 1 (one) acre immediatety
"A
surrounding residential improvements.
Other land
(2)
Total land (line I plus line 2)
(3)
Dwelling
(4)
Residential Improvements or Annually
Assessed Mobile I Manufactured Home
Garage
(5)
(�Wt improvements
(6)
-z
Total Improvements (line 4 through line 6)
(7)
Total value (line 3 Plus line 7)
(8)
1 hereby certify the above is true, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
Wua, x.s STANDARD;DEDLICTIONALLOWANCE--
20_Pay2O_
Lesser of 112 Homestead
Valuation or 535.000
Signature of Auditor
Date signed
6:vo-ox
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