Homestead_Davis (3)CLAIM FOR HOMESTEAD PROPERTY TAX FoFtM �
_ STANDARD / SUPPLEMENTAL DEDUCTION HC�o
" SFate Fam 5473 (R13 / 12-09)
�,�� � PresaiDed by Ne DepaM�ent of Lacal Govemment Finarwe
INSTRUCTfONS: See ieverse side !or filirg instruetlons.
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I(We) ceAify that I(we) occvpied as my (
place of residence w am (are) buying the fdlowing de real property for which a Homestead Property Tax Standard Ded� is,h0/e�X; aimed
urder mntraG on the date this appliption is filed, (date of filing). I(We): G`S �� 2
Own ❑ Am (are) buying under recorded contract C"�� M^�
Am (are) enfitled [o occupy as a tenant-srockholder of a coope�ative housing corporaHon GIBdS�
❑ Have a benefidal interest in the Wst or Ne right to occupy the property under the terms of a quaiified personal res� �GrS�CNTY q�0170R
❑ Am (are) the shareholder, partner or member ot Ne entity that owns ihe property.
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Na nt(kg/a�lneme)
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sodel seaniq nwr�e, � o damaoucense �� ���mum � rnner �
Na N ImanPsspase{kga/name)
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Soflal
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If buying on convacl, Fee Simple ownels name
Recorders office wAwse mnusd is recorded Rernrd numbar Pape
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� To+�nshiP � (crtl: to � IownshiP)
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Paicel number A,,.�� Legal tlescrlption Is IM � in Question:
a_ 7-a �-�Q�—(�J� 3'� � I qoperty nually essessed mob0e home (IC Gf.1-�
�ot Na p�iopeny u�tifized m�uproAUS� mmer the land nol exceeding rne (1) afre ihat immetliatey surtoun ihat sWCNre ¢ used m produce income. Cesaibe the use and portbn
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Counry TownsAip Caunry TovmsNp
I hereby certify the above statemenis are We, cortect and complete. - Sgnawre of da"unaN
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nedress (number erd shaet, riq: stare. ard zw caee) 1
n+12.��a�Q � a.
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Land not exceeding 1(orre) aere immedlatety �� � �.`,t ��=,�..y,`'��,,�� �` �,1; .: Ss�.�
surroundin residential Im rovements.
Otharland (2) � � �� ���'
.J�. �� ��Y �� n
Total land (line 1 plusllrre 1� (3)
i 'm..� ->a2�ss� � � `"1
ResideMialimprovemenfsorAnnuaily �BIIIn9 (4) z'rf i a :--� �- �.��"�;
Assassed Mobile I Manu(ac4ired Hwre .-i_> �" _"�g. a'f�' s;..-� 3�rs' .� :-�
Garage i5) �.�..-�` ,� _�^ �,.n-`::
s �-r�
Other Improvemenb (C) } � „c. ,'�''' F
Total improvemeMS (llna 1 throug� line � (7)
Total value (line 3 plis Ilne � (8)
I hereby certi(y the above Is We, correet, �9"a�re ofASSessor Dete signetl (monlh. deY•Y��)
and wmplete.
Verifyug aWon - Signawre af Auditor Qam s9� (rt�wrN, tlaY. Y��)
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_ pay 20 _ Lesser of 60% of the essessed value of the homestead or $45,000
Nolwilhstanding any othe�provisid�, fhe sum dfhe de0uctions providM in IC bf. f-12 to a rtnW7e home Nat is $
not assessed es real propeM w ta a menulactwed homa Mat is rat essessad as rael property may rot exceea
c�r, �21 a essassed ven,e arna ron,e w me�wam�rcd na�e.
�� ,{� �� � Date signeA (month. daY. Yea�)
7