Homestead_Bennett (2)• 3
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' """ CLAIM FOR HOMESTEAD PROPERTY TAX
_ ? STANDARD / SUPPLEMENTAL DEDUCTION
S State farm 5473 (R12 / 609)
�O 1 PreuADeO by Ihe Department of Local GovemmeM F�nce
�(NSTRUCTIONS: See reverse side !or filing instrtiUans
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i
FORM YEAR
�I ��
AUG 9 2011
I(We) 1 - ceAiFj Nat I(�r� ar2vpied as my (our) prindpal
place of re ence o (are) buying the following described real property for which a Homeste�(����i�a�n is hereby daimed
under conVad on lhe date Ihis ap�cation is filed, (date of filing):
❑ I(We) own ❑ Am (are) huying under recorded conVact
❑ Am (are) endtled to occupy as a lenanl-srockholder of a woperative housing corporetion
� Have a beneficial interest in the Wst or the right to occupy the property urWer ihe terms of a qualified personal residence irust
Recad number � Pape
�� V� I ��0� � O�+ D�� VOLO I15 ❑ Real WoPertY �� � MnuaM assessed mod'le home (IC &1. f.,
portion ol Ihe resitlential sWCW re w Ne lantl nol axceedtrg one (1) aae that Immediatety surtounES that sWCture is usetl to produce i�xome, Eescnbe Ne use and portion
P�PenY uGl¢e0 W P�uc¢ inmme.
�u�,f�. as�t
Counry
Tawnship
I hereby cerafy the above statements are we, mrteU and complete.
AtlOress (num stmet, at}; sleta, and LP code)
��)�/ /.d � ;��.�`�.,��-
Land not exceeding 1(one) acre Immediately
Olherland
Tofal land (line 1 plus line 3)
Residential improvements or Mnually �����9
0.ssessed Mobile I Manufactured Home Garage
Olher improvements
7otal improvementa (line 4 rhraugh line 6)
Total value (llne 3 plia line n
I hereby certify the above is Wa, correct,
and complete.
Veifyi�g adion - SignaNre o(lwtlitw
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I�1�`I� �
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Counry
20 pay 20 Lesser of 60°6 of Ne assessed vaiue ot the homestead or $45,W0
Nofwilhsta�ug eny otheiprovision, Ne sum o! the detlucfivts provMetl in IC &7.1-f 2 fo a mob�e Mme fhat As
rot assessed es real property a lo e menWaaured home Nat is rrot essessed as real pmperry may not eaveed
Township
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8
Dace signed (month� daY. 3'��)
Date signetl (rtwnN, day, yea�