Homestead_Sullivan° CLAIM FOR HOMESTEAD PROPERTY TAX
__ STANDARD/SUPPLEMENTAL DEDUCTION
Shate Fam 5473 (R13I 12-09)
� y„ f PresaiDed by the Department af Local Govemment Finarce
INSTRUCTIONS: See reverse side (or filing instiucUons.
FORM
HC10
i �wel ' r1 �Y�.dA.O�. certify that I(we) occupied as `hYC�ti VrinciPal
place of resfdence or am (are) buying ihe fdlowing described real property tor which a Homestead Property Tax Standard D�du�I�,��aimed
���der conhact on the date ihis appliratio� is filed, (date of filing). I(We):
�' Own ❑ Am (are) buying under recottied mnVSCt CaIBSON COUNTY AUDITOR
❑ Am (are) entitled to occupy as a tenanFStockholder of a cooperative housing corporation
❑ Have a 6eneficial interest in Me Wst or the rignt to ocwpy the property under the terms o( a qualified personal residence Wsl � .
❑ Am (are) the shareholder, partner or member of the entity ihat owns the property.
Seairiry
fiie dyi5)
spousa
�{ p�yNg ��nt2G, Fee Simp�e owne�s name
mnuaa
Counry
of daimant (last fire digifs)
Ofivei s Ikense / Identlflcation / O�her number
of daimanYs spouse (last frve dyils)
Tamg
��
fown,
luuirg Sate
Record number � Page
Parcel nu ber legal tlers�a�iption I Is � perty in 9uestion:
�� '0 �.��. �O `��O• �' O�J Real poperty � AnnuaOy as5es5eA mob0e tprne (IC Gf. f-71
If arry portbn ol the resManUal structure or the WrM ra� ezceeding one (1) aue ihat immadiatey wrtounds ihet sWdure is used lo produce irmme, tlescnbe the use and porlbn
of Ne P�rtY u6lized in proCUCe Inroma.
V ��,5� S�ISB
Caunry
I hereby ceAify the above statements are We, cortect and complete.
Lend not exceeding 1(o�l acre Immediatary
Other land
Total land (Ilrte f plus lina � .
Residential Improvements or Annualty
Assesaed MoDtle I Manufactured Home
Other Improvements
Dxrelling
Garage
Total improvemeMS (line I fhrough line 6j
7ofal value (line J pl�s 11ne 7)
I hereby cerdfy the above is We, correct,
and complete.
Veiymg edion - Signawre oflwtlimr
(�)
(2)
(3)
(4)
(5)
(6)
��)
�8)
Sig�ture otASSassor
Counry
of da'unant
20 _ pay 20 _ Lesser of 60% of the essessed value oi the homestead or $45,000
Ta»ishlp
Dete
Date s�ned (mmth, daY. Y��)
STATE FORM 53569(8318-10) TREASURER FORM TS-IA
, APPROVED BY STATE BOARD OF ACCOUNTS,2009 PRESCRIBED BY THE DEPARTMENT OF LOCAL GOVERNMENT FINANCE IC6-1.1 22-8.1
IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS$.
Individuals and married couples are limited to one homestead standard deduction. As the receipt of this
deduction becomes more beneficial, there is more incentive than ever for homestead fraud. Homestead fraud
•:auses higher tax bills for all; therefore, HEA 1344-2009 requires taxpayers who receive the homestead
standard deduction to verify that they are eligible to receive the benefit and to provide additional identifying
information necessary to allow county government to better monitor homestead filings. This information
will be kept confidential and can only be accessed by authorized county officials. The Department of Local
Government Finance will use this information to create tools that will help county officials eliminate
homestead fraud.
PAR I: PROPER Y INFORMA ION
Taspaver Name Property Addres1 ,State Parcel Number Lent Description;
Tamara Sullivan 106 N WOOD ST 26-04-25-101-000.084-020 H&S ENLG 57/58
PATOKA IN 47666
Complete and return to: 111[1hIllu11MUMEIMEIMI10m IR QOID11111IIt1111
GIBSON COUNTY AUDITOR, 101 N MAIN PRINCETON IN 47670
PART 2: TAXPAYER INFORMATION . . — -till
Owner 1 First Middle Last
TA rand Su / 1 ( visa)
Mating Address(number and street city,state and ZIP code)
Same as property address
Soouse First Middle Last
Mating Address(camber and street city,state and ZIP code) Sane/as properly address
Social Seamy Number(last 5 digits) Drivers License State ID Number(last 5 digits) ems Other(please specify in Part 4 below)
PART 3: CERTIFICATION u
Each undersigned certifies,under penalty of perjury,that the above and foregoing information is true and correct and that he or she is eligible to receive the
homestead standard deduction on this property. Each undersigned also understands that,by claiming additional homestead deductions unlawfully,he or
she may be liable for back taxes and substantial financial penalties.
Owner 1 Signature Date
Spouse Signature Date Telept/one
PART 4: ADDITIONAL INFORMATION > _ -
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