Homestead_Kern (3)"' CLAIM FOR HOMESTEAD PROPERTY TAX FORM �
_ STANDARD / SUPPLEMENTAL DEDUCTION HCto
State Fam 5473 (Rt3l 12-09)
� y� � Presmtad by the Departrnefrt o( La�l Gwemment Finance
INSTRUCTlONS: See reverse sfde /ar filing ins6uUions.
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I(We1 �— certify that 1(we) ocapied as my (our) principal
place of r dence a am (are) buyirg the fdlowing described real property fw which a Homestead Property�c �St�Q�rce9�uction is hereby daimed
urWer contract on the date Nis application is filed, (date o/ filing). I(We):
�Own ❑ Am (are) buying under recorded conUact C-����4 f�
Am (are) entitled to occupy as a tenanFStockholder of a cooperative housing corporatlon v v R
❑ Have e benefidal interest in the wst or Ne righi to occupy the property under the tertns of a qiiai��pe�soii�al i�sideii�� W� t •
❑ Am (are) the sharaholder, partner or member ot Ne enfity that owns ihe property. �
•• • •
Name daimam(kgel �.�Y��
Sadal lY nuMer of dacrent (65 (ne dg�) �Driv�ficense /� ��tion / / Issuirg Slate
Nart�g pl ��
\J ) %nA-
Social Seariry numbar af tlainwnt's spouse (last five d'gfts) Drivers Ike�e / Itlentifiplion I Other number IssWng State
• �-� �
If buying om m�trdd, Fee Simple owners name '
Recordefs WGw where conuaa is recorded Remrd number Page
..�. . � . �
Counry imvruhip 7aring dctxt (crtY. town� rownship)
Parcel number Legal desuiption Is tha pmperty in puestian:
� Real propeny � MnueVy essessed mob0e hortre (IC 6f. f-7)
If arry ponion of Ne residentlal structure or the Wn0 not exceedinp me (1) aae Nat immedatey wrtountls that sbucYUre is used to pro0uce income, desaibe Ne use antl pation
of Ihe propam/ utilizeE in producg Ncame.
c�- 8-a -yoo- - -oa5
-.• . .: . .
Counry Toxnshlp C��b •. T��V
I hereby certiry the above statements are we, comect and compiete. �^��1re ai nt
�
Addreys (numDer aM sLeef, dty, stare, aM LP coda)
X
. . .. . .
� • • „ . . ,,,
land na exceeding 1(orre) a«e fmmediateh (�� - .� L, f� ,.�r�,'„��}�.��y, K� '�
surtoundin realdentlal im rovemefrts. -
�K`4 ..'."_'7,�r K�'- '
ONer land (2) ,_ cz .,�,: �„'�sy r:.
romi iana (�,rre + a"s ir�e � (3>
- i�' � Yt i- .�-C��-. ...�'s �%
Residential Improvements orMnuafly �Iling (4) � ._ ;,3,. —�# „e�__, ..� 4 .w;.=;,�;-F'
Asaeased MoDtle I Manufa�tured Home s.,,� ���.�-_� �" -,,-.s,,.- :'s:.
Garage (5) .x�m t �x=:- '�� -:��"'-,��'.
Otherlmprovemenb (b) s �"Y ,.4?;�'; ���
Totel Improvemerrts (line / fhrough fine 6� (7)
romi vaWe �nna s pl�a nne n (e)
I hereby certify the above is We, eorreet, �a�re of Assessor Date aiB�d G^�^�. �Y.Y��)
and eomplete.
Vaify'uig adion - SignaWre MPUtlitor
Dam signed (month, daY. yea�
�.•t � � • •
20 _ pay 20 _ Lesser ot 60% of the essessed value of the homesteaC or $45,000
NohHthslHnding any oMer pmvision, (he sum ol fhe deductions provided in IC 57.1-12 fo a nro6ile home fhaf's $
not essessed es real poperty a fo e manWactured home thet is not essessed as 2al property mey raf exceed
one�hel7 iR) d Ne euessed vafue W the mobde hane ormanufactured home.
Signan�ra af NMitw Date signeA (month, deY. Yea�