Homestead_GoadCLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD/SUPPLEMENTAL DEDUCTION
` " State Form 5473 (R13 / 12-09)
� " Prespibed by the DepaMient of Local Govemment Finarxg
4M
INSTRUCTIONS: Sae reverse slde lor filing insfn�ctlons.
FORM
HC10
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1(We) cerGfy that I( s my ) nci I
place of residence w am (a uyi'y the fdlow'uig described real property for which a Homestead Property Tax Sfan D
urder coniract on the date th application is filed, (date o�filing). I(We):
�Own ❑ Am (are) buyirg under recorded contrect NOV 2 6 2012
� Am (are) en6lled to occupy as a tenent-stockholder ot a cooperative housirg corporation C�
❑ Have a beneficial interest in Ne Wst or ihe right to ocwpy the property under lhe tertns of a qualified personal residence Wst '
❑ Am (are) the shareholder, partner or member of Ne enfity that owns Uie property. GIBSON COUNTY A IT R
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Nemed islegalnartre)
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soael
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Name ol dalmant s spouse (lega/ nama)
SaUal Sea�riry numhar of Ua'vnanYs spousa (kst flve dgits) Drivefs 16xnsa / ItlanM�cetion / Other number IsSWng State
of da4nanCS spouse (Wst five digits)
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If buying on cantract, Fee Simple owners name
Recorders oiGca where contred is recorded RecoM numher Page
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Counry � Township Tax'vig '�wn, townshi
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Pa� num L " tlon Is the perty in questian:
�� a—�O Real pioperty ❑ AnnuaOy essessed moDOe Imme (IC &f.7-7)
It anY of the residentlal sW cture or the WrM not ezceeding one (1) ecra lhat immediatey wrrou Cs that sWUwe ia used to produte inmme. desaibe the use an0 poNm
d the rty utilized m produre Income.
��-�a-aa- �a�-va�. �o.�- oa�
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Counry Twmship Counb TownswP
I hereby certiy the ebove statements are We, correct and mmplete. Signacure of daimant
�p�barantl 4�Y.uete. LPCOde)
� ` 37�I�E So� Pri�CP�6n �n/ 4�6�a
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Land not exceeding 1(o�re) aere Immedlatety i:?�yr �.�' u Yx"�� ..� ;��'��.
su+roundln rasldentiallm rovements. ��) --°^=• �t�'��-� r�.�=`—'3=�''
Other land (2) � s'S'J,,,,'F".'-�<us3.'J'�
Total land (liire 1 plus llrre 1) (3)
�.�:.i�.Z•+f -�.,� ^�.- e
ResidenUal Improvements orAnnuafly �IIIn9 (<) -�' � :i"+�'� �';?' 9 �� � �� .
Assessed MobOe / M3nufaCtllled Home G�ee (5) �--.�,� r��Y-.q:.,GSF`,� �� �
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Qther Improvementa (8) � +'� r � ��`,
Toml improvamarrcs (Ilne 1 Nrough line 6� p)
7otal valua pine 3 plis Ilne � (B)
1 hereby certlry the above is true, correct, �8^adre otl�sessor Date signetl (monM. day, yea�
and complete.
vaif�vig acYim - si�awre of fw6tor
DaM signed (rtanlh, daY. 1'��
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20 _ pay 20 _ Lesser of 60% of the assessed value of ihe homestead or $45,000
NoMithstendLg any oNer provision. ffa sum a/ fhe deductiorts pmvidad in IC bf.7-f 2 fo e nnWe horne Me1 is $
not assasmd as real pmperty w M e menNaaured home Nat is rot essessed es real property mey rat esceed
one-nan /irz� oi nre essessee van,e a�ne � rmme o.menwauured n�.
Sig`aWre of AWitor Date signed (monM, daY• 1'��
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