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Homestead_Haas"'" CLAIM FOR HOMESTEAD PROPERTY TAX
_ � STANDARD/SUPPLEMENTAL DEDUCTION
State Form 5473 (R72 / 609)
�O � Pres(si6ed by Ne Departmeiri of Local GovemmeM Fnarce
INSTRUCTIONS: See raverse side far �rg insWclions.
. I �
'� ' t- 1 i��
� _
g 12012
I(We) �-- ceniry Nat I(we) occupied �S` ny�L r) prindpal
place of residence or am (are buying the toli ng descrihed real property for ich a Homestead Property Tax Standa N COurticnis�§�bj�med
�{{u__n....d,,,,e,,r conVad rn the date Uis appliwtion is filed, (date olfiling): GIBSO �� ��
(We) own ❑ Am (are) buying under recorded conVact
Am (are) enUUed to xwpy as a tenant-stockholder of a cooperetive housing corporelion
� Have a beneficial interest in the wst or the right to occupy the property under the tertns ot a qualified personal residence Wst
'
Remrd number � � Page
Parcel number l.e9al aesrnD�+ , I �s e perty in quesfo�:
a, f�' L�'i �1 -�o�.��a -bl—I �ia�wem ❑ nN,��re��amowen«�uc�i.�-n
If any portirn o( Ne �esidential swcwre w 1he W� rwt exceedNg me (1 acre tha[ immeEiatety surtounds �hat shucNre is used tn pmduce income, OnsMbe the use anL portion
of Ne properry uoT¢ed to pfoEUCe inmme. ,
Courrty
I hereby certiy the above ststemenis are we, cortect and complete.
Atltlress (numDer and sUee4 �+N, ��e, and LPtoda)n
� S7/`7 /J �fSO E , /✓RT�I<A . Ii
Land not e:ceedi`g 1(one) acre immediatety
Otherland
Total land (line 1 plus line 1)
o�.�en��9
Residential improvements or Mnually
l�ssassed Mobiie 1 ManuFaceired Hane Garege
Other improvemertts
7ofal improvemenis (line / Nrough line �
Total value (Ilne 1 plis line �
I hereby certify the above is hve, wrrect,
and complete.
Vaityi�g acAOn - Signature al f�udmr -
i�)
cz>
(3)
ia)
(5)
(6)
Caunry
20 _ pay 20 Lesser o( 60% of the assessed value ot the homestead or $45,000
AblwiNSlaMUg enyWerprouision, Ne sum d fha derluctione piovidetl in IC G1.1-f2 ro a mobde home Nat is
rot essessed as real properry ar fo e menufeGUred home Na( a not asseued as real poperry mey not e+ceed
TmvfsAip
Date slgned (rtronfh, day, yea�
Date signed (monN. day, yea�
$
Date signed (monfh, day, yea�
