Homestead_Hamm (6)CLAIM FOR HOMESTEAD PROPERTY TAX
_ STANDARD / SUPPLEMENTAL DEDUCTION
State Fortn 5473 (R13 / 12-09)
� - PresaibeE by the Department o( Local Govemment Firiance
INSTRUCTIONS: See reverse slde !or fifirg instructions.
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OCT 1 l 2012
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��yye� � certify that I(we) xapied as my��r) principal
place of residence w am (are) buying the following described real property fa which a Homestead Property Ta; 9� „ �Q,�U(BtAs'h8�d8imed
er mntrad on ihe date Nis applintion is filed, (date ol filing). I(We):
Own ❑ Am (are) buying under recorded contracl
Am (are) entilled to occupy as a tenant-stockholder of a cooperadve housing corporatlon
❑ Have a beneficial interest in ihe Wsl or the right to ocwpy ihe property under the tertns of a qualified personal residence Wst .
❑ Am (are) Ne shareholder, partner or member ot the entiry that owns the properry.
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Name of daimant (kga/ neme)
Sode�.°iemitY nurti6ri of tlaunenl (kst B.e d�pks) Orivers GcenSe I IdenGfiration /
rt
1.
N e of daimants
SoGal Seartiry num6er of daunanYs spouse (last fi�e d'glls) D�ivers lifa'ae / Idmtifiration I Olher wmber Issuhg Sta[e
ot daimanrs spousa (last rrve dpiCS) � �
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It buyug on contrart, Fee Simple owners name
Recorders of6ce W�ere contract is rerorded Record number Pege
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��, TownshiD Taring disfid ciq: town. rownship)
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Patcel number Legal tlescriPtion property in 9uettion:
a -1�l-lg-IDl-dbb. 3-Oa R�woa�r ❑ r�,�nr�a�men��ic��.�-n
If airy portion o/ the residenilal sW ctura or ihe IaM not exmedirg one (1) ava ihat immediatey wrtountls tha[ strudu�a is used to produce u�come. desaibe Me use ard patiai
ol Ue property utilized to proCUCe Income.
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Counry Tamship Counry Townshlp
I hereby certfy the above statemenis are We, corred and complete. �41e °� "� . f'�%
naaress��umae.ene �Le�ary (oar�LUa9C/C�q/W G l�i �'�� �%��D °
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Land not exceeding t(orre) aere ImmadiateN � Y- �°_-' �� �.z`. �""i-z �c .�'; .'r'
surtoundin rasldentlallm rovaments. � ) ��=�=—`s� �� "'f`�"��'
.i� _ {.�+_,y ��_.
-r'�• � 3.'"�-`_, �a, F .ro ".
�V1E� �8I1f� �2� 3.i. !2. _�S..-Absia
roml land (Itrre 1 plus rirre � (3)
. 1:?,? �-�..� � " '
ResidenUal Improvements or Mnually ���Ing (4) i� �t' a�:.�.r,. r i� �w�'-.�—.
ASSrssed MobOe / ManufacLired Home �ye (5) �:���� ��g -£.s- �����
A 'Y.t ��:,Q��
Other improvements (C)
�1 �r t �. r,2�Y�:
Total improvemeMS (Ihre 1 thiough line � (7)
Total value (/Ine 3 pl�s line � (8)
I hereby certlfy the above Is We, correet, �9"a� of Assessor Date signee (monfA, deY.Y��1
and complete.
Vaifying actbn - Signanire of NWitw
Dam signeC (month, daY. Y��)
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20 _ pay 20 Lesser of 60% of the assessed value oi the homestead or 535,000
NoMithsfantling eny oNer povis�on, Ne wm o/Ne deductions providetl in /C 61. f-12 ta e mobl7e Mme Nat a $
not essessed es real pioperty w ta a menNaGUied homa Maf is ra( essessed as reel properry mey rrot erceed
w�e�hetl 12) W Ne essassad value o/Ure rmWe hortre w man�daUUred home.
Sigahue of /Wtlitw Date si9ned (month. daY. Y��
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