Homestead_LittleCLAIM FOR HOMESTEAD PROPERTY TAX
_ STANDARD / SUPPLEMENTAL DEDUCTION
State Fortn 5473 (R13 / 12-09)
� Presctibed by the Department of Local Govemment Finance
lNSTRUCT►ONS: See raverse side for filing instructions.
FORM
HC10
YHAR
;
��e� � /' /��� L_�� certify that I( Ried as my (our) prinapal
place of residence nr am (are) buying the following described real property for which a Homestead Property Tax Stand�edu�jio��aereby daimed
under contrect on the date this applicalion is filed, (date of Bling). t(We): �
C . J. f���t3 `` V
❑ Own C] Am (are) buying under recorded contr�ct
� Am (are) entiUed to occupy as a tenant-stockholder of a cooperative housing corporation GIBSON COUNTY AUDITOR
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a qualified personal residence trust .
Q Am (are) the shareholder, partner or member of the entity that owns the property.
Name
Sodel Sewrity number
��
Name of GaimanYs spouse (legal name)
Soclal Security number of claimanYs spouse (last five
If buying on contract, Fee Simple owner's name
Recwders oiGce where contract 1s recorded
Couniy
Drivers license / IdenUficatlon /
��
Driver's license / Identification / Other number
of daimant's spouse (last five d!y'rts)
Taxing district (city, town, township)
issuing State
Issuing S'tate
�
Record number Page
Pa number Legal description Is the propeAy in question:
I � �/O� � 111R�R\ O n�'� /'1 ❑ Real Property ❑ Annually assessed mobGe home (IC &1.1-n
i [ilJlJ r �v
If any portion of the reaidentlal structure or the Isnd not exceeding one (1) acre that immediately surrounds that structure �s used to prpdu� income, descnbe the use and portion
of the property utilized to produce Income. � ���
�;� �
County
Township
County
I hereby certify the above statements are true, correct and complete. '[
Address (number and sheet, city, s te, and ZIP
�'� '�. c��nk�ec �l, �� Qc�-.�0�� �
Land not excesding 1(one) acre immedlatey
Otherland
Toml land (line 1 plus llne �
ResideMial (mprovements orAonually �����g
Assessed Mobile / Manufactu►�ed Home Garage
Other improvements
7ptal improvemeMs (line � tl►rough line 6)
Total valua (Ifne 3 p/us ilne n
I hereby certify the above is trve, correct,
and complete.
Verirying adion - Signature of Auditor
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i2)
(3)
(4)
(5)
(6)
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�8)
Signature of Assessor
�
20 pay 20 Lesser of 60°h of the assessed value of the homestead or $45,000 I
A
Township
�
Date signed (month, day, }rea�j
Date signed (month. day, yea�j