Homestead_Fithian (3)° CLAIM FOR HOMESTEAO PROPERTY TAX
__- STANDARD / SUPPLEMENTAL DEDUCTION
. . Sfate Form 5073 (R73 / 12-09)
�,�„ ! Presaibed by the Department of Local Govemment Finarice
FORM
HC70
ICi%!AJI
�rv� i n�� i �una- �ee reverse aoe mr nung msrn�cmns.
. �
I(We) ce�rtiy t I�ej� � s (our) priruipal
place of residence or em ( j buyinq the following descnbed real property for which a Homestead Property Ta,��Tndard DeducUon is hereby daimed
�er contraU on the date is application is filed, (date o/filing). I(We): �� 2 2 2012
Own ❑ Am (are) buying under recorded conVect C.�.�
� Am (are) entitled to occupy as a tenant-stockholder of a cooperalive housing corporation
❑ Have e benefidal interest in Me wst or the right to occupy the property under the tertns ot a qualIDB�tpe s� ence st .
❑ Am (ara) the shareholder, partner or memher of Ne entiry ihat owns the properry. �v�'�Y A�DITOR
•• • •
Nama of tlalmant (legal name)
So�
name)
SoGal Seairiry numbar af tlaunanYs spouse (WSt Irve digks) Drivers licensa / ICentlflcelion / Ot�er numDer Issuing State
of daimanrs spou.^,e (last five digittl
• �•� �
If buying on tqntract Fee Simple ownets name
Remrders ofice where mntred is iewrded RecoM num6er Page
"�• ' � • •
Counly TownshiG Taring disUitl (city, town.IOwnshiP)
Patcel number L al d85rription �7 Is tha property in question:
c� - -/ - 6 0 CS�C% � 7' — Rea� poputy ❑ annuaoy essessea rrwsue home (tc s-�. �-7�
�W Ne P� utilized b protlu� comer Na t exceedinp one (1) acre thai Unmediatety su'munds ihat strumre a used to Produce u�coma� tlesaibe the use and W�1bn
��-i�-i9-3oo �� a. oa � -oas
... . . : . .
County TownshlP CounN TownslJp
I hereby certiy the ebova statements are true, correG and complete. Si�aw�e o( '
�
Pdyres;(numbereMStreet,tily,518tB.aMZIP e)
X 6 S ca 'w• O �-<- ��, s �,' l � � S
.- .
. . •. . .
„..
Land not axceeding 1(orre) acre immedlately � .�$�.���.'�r Y�. ���y?
surtoundin residentlallm rovements.
( ) .-:.a� a'� aSS� z . a:
Other land (2) ,�F c G ,�:�'��
.t� ° -wsrx.�`s�.�e'
romi ia�e pme � pros u�e � �3) f ��{
'W�F�:.�+]"'YC � 7 �Y Ti�`�
ResidentlallmprovementsorAnnually �IIInB (4) �. d,'. �` � �„*Fr���.c:,�'.
Assesaed Mohle / Manu(aetured Home Garaga (5) ��x '`� -�'�.-:� �� �� � �
Otherimprovementa (6) ��� c�K=.��r`;
Totnl improvemerKS (line I throug� line 6� (7)
Tota1 value (line 3 pl�s nne 7) (8)
I hereby certify the above Is We, correet, �9��re ofnssessor Date signed (month, dey, yea�
and complete.
veiM�9 aawn - sigrewre or a,dimr oate signea (maim. aar• s'��)
�..� � � • �
20 _ pay 20 _ Lesser of 60% ot the essessed value of the homestead or 545,000
No�vithsfending any olher provision, fhe sum o/ Ne deducfiorts provMed in IC Ef. f-72 ro e rmb+7e hwrre Ihat is $
not assassed as reel proparty or ro e menufactuiad home that is not essassed es real ploperty may mt exceed
one-haf/ 12) W Ne essassed re�ue dfhe imdle home ormenWactured home.
SigneIIUe of IWAitd Date signM (monfh. daY Ye�
y