Homestead_Sias;.._t
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CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD/SUPPLEMENTAL DEDUCTION
Shate Form 5473 (R73I 12-09)
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FORM
HC10
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INSTRUCTIONS: See ieverse slde lor filing ins6uclions. �
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I(We) certiry ihat I(we) i as ��'Qur) prindpal
place o( residence or am (are) buyirg ihe foliowing described real property for which a Homestead Property Tax Standa�u�on is hereby daimed
under contract on the date ihis application is filed, (date ol filing). 1(We): C�.n�
�Own ❑ Mn (are) buying under recorded contract
Am (are) entilled to occupy as a tenen[-srockholder of a cooperaGve housing corporetion p�gSON COUNTY AUDITOR
❑ Have a 6ene6dal interest in Ne Wst or the right to occupy ihe property under the tertns of e qualified personal residence wst .
❑ Am (ere) the shareholder, partner or member of lhe entlty that owns lhe property.
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NameNdai (kga�name) o
Sod� rpanherdda4renl�lAe ) ofdaiman�l���� Iss�ug
Nartm o/
Sodal Securiry number of daimanYS spouse (Wst frve d'gRs) Driver s fice�e / IdenUfication I ONer numbar Issuing State
ot daimant's spousa (lest five digtts)
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II buying on cont2d, Fee Simple ownefs rame
Rxwdets oKxe Wiere contrerl is recorded Record number Pepe
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Counly / \ Tamship Tarin9 �� (�l% town� townshlP
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Parrel num6er Le esaip' I Ihe perty in Question:
� — 3��� Real proprny � AnnuaOY essessed mob0e hortie (IC Gt. t-n
If any � n of Me msidenUal sWCCUre w Ihe land �al exceeding ane (1) aae thet immediately surtoun ihat sWCture is usad to produce incame, desaibe tha use aM portion
W Ne nY uti➢zetl to Wudure Incoma. /�j/) /li�.
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County Tow�uhip Counry Townshlp .
I hereby certify the ebove statement5 are We, cortect and mmplete. Signanue t aimant� `
dress(numDe�anOSf+ect,rity,sfe�� ZIPmCe1 /
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land not exeeeding 1(o�re) aere Immediatey �� � r'�"��rt �',�'x„ri'�,,,!;
surtoundin resldenLal lm rovements. ��) .� � ��� ��i �".
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Other land (2) 1 a ..,,a�?.,.,,_
Totel land (line 1 plua Il1re t) (3)
Dwelling (4) y � "`�'.€*�`r �-'�i��d-�cK;Q,�'._-��
ResidenUal Improvements or Annually . .. .
Assessed Mobtle / Manufantured Home Gara e `��� .,`t���� ;.�'t�`�"'�..,�#�:i�=r'
9 (5) ?4��.�._.,_..r_=.a_._,=.. �-_-. ....,:.�
Other improvamenb (b) j� �.�-.,?�;?j�t"'�' �
Totel improveme'rts (!!ne I through line � p)
7ota1 value (line 3 pffs fine � (8)
I hereby certity fha above Is true, cortect, �9^a�+re ofl�ssessor Date signed (monrh. daY.Y��I
and complete.
Vairying adlon - SignaNre of MMitw Date si9ned (monN. day, yee�
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20 _ pay 20 _ Lesser of 60% of the essessed value of the homestead or E45,000
Np(rilhslendLg any oflrerprovisiory fhe sum W(he deducfims povidetl in IC f.f. f-f2 ro e rrobi7e home Maf B $
not essesse0 es ieal propertyw ro e menNarlured homa thet is not essessed as real propery may rrot exceed
one�hall 1R) 07 Ure essassed relue altM rtro6ile home or man�Aactured home.
Data signetl (rtan(h. daY. Y'�aA
SignaLUe of Auditor .. ... .