HomeMy WebLinkAboutHomestead_CookCLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
t State Form 5473 (R614 -03)
Prescribed by the Department of Local Government Finance
INSTRUCTIONS: See reverse side for riling instnictions.
FORM
HC10
le= :i•_, - -.sue .i- -,e y..r :�.. -:-, _r.; `:„ ,f s ? .?` GERT1FICATION STATEMENT"` i
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I (We) certify that on the 1st day of March, 20
1 (We) occupied as principal place of residence the following described real property for which a Homestead Propel axT Credit ishereby claimed:
❑ l(We)owned ❑ Are buying under contract or C/
GIBSON COUNTY AUDITOR
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.
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�NTR/1CT.'RECORDED � —� 5�y._.�:V,s
If buying on contract, Fee Simple owner's name
Recorders office where contract is recorded Record number Page
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County
Township
Taring district (city, town, township)
Par Ipugibar ^��
IC_/ (_IJ
L 'D on
Is the property in question:
®dre (number and street, city, state, ZIP code)
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�VALUE�LsVALU?
❑ Real property ❑ Mobile Home ( /.C. 61.1 -7)
If any portion of the residen0al structure or the land not exceeog one (1) acre that immediately surrounds that structure is used to produce income, describe the use and portbn
of the'Frperrty Utilizze� produce income.
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County
Tvvnship
County Township
I hereby certify the above statements are true, correct and complete.
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VALUES.,
®dre (number and street, city, state, ZIP code)
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ASSESSED VALUE
HOMESTEAD
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a' NONIRESIDENTIAU.
vaivauon or 535.000
VALUES.,
AT100 %0FyTTV-
�VALUE�LsVALU?
,
Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
(1)
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a`2.,
v
Other land
2
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Total land (line 1 plus line 2)
(3)
Dwellin 9
(4).i�Ya'u
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Residential improvements or Annually
Assessed Mobile I Manufactured Home
Garage
6
_ _�
r1 �
W
Other improvements
Total improvements (line 4 through line 6)
(7)
Taal value (line 3 plus line 7)
(6)
hereby certify the above is We, coned, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
' 3> 'f -•=,r ui° r` isv`l- s..r'ma r'? TANDARD'DEDUCTION'ALGOWANCE? A3-
20_Pay 20_
Lesser of 112 Homestead
FS
vaivauon or 535.000
Signature of Auditor
Date sign
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