Homestead_Foster (6)CLAIM FOR HOMESTEAD PROPERTY TAX
_n � STANDARD / SUPPLEMENTAL DEDUCTION
S� Stata Fortn 5473 (R72 / 6-09)
� f PrescnEed by Ne DepartmeM of Loml Govemme�n Frerce
INSTRUCTIONS: See reverse side !w fifiig instrudions.
I� � I: '�� � jl)� �
DEC 21 2012
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1(we) certiry ihat I(we as my (our) vrindpal
place ot res�dence or am (are) buying the following described real property for which a Homestead 01�SQ�IP3391�Ad61H.�tld�7'QRs hereby daimed
under mnttact on Ihe da[e this application is filed, (date o/filing):
I(We) own ❑ Am (are) 6uying under recorded contract
Am (are) entiUed to ocwpy as a tenant-stockholder of a cooperetive housing corporetion
� Have a beneficial interest in ihe Wst or the right to occupy the property under Ne terms of a qualifled personal residence Wst
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Name of daimant (k9al name) '
$odal Seqrtity nmEn�yf daerant (fast +F�$ J Orivers Iirxnse / Identifration /
Name ol daimani's spouse (lepel neme)
Sorial Seanry numba of tlairren['s spause (Wsl five dgds) Drirers Ikense / IdenY,uztion / ONer number Issuu�g Stafe
ot daimant's spouu (last frve C'yitcJ
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H buymg om m�traq Fee Simple wmefs nama
Remrders ot&s where contrad it iewrdeE Record numbrl Page
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� Twmship T' ¢ G(" M, towruhip
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Parcel number �D� 1 T I I�e 0 P�Y � W�tion:
� d'o� —�Q ��. � Rral P�7enY ❑ AnnuaDy assessed rtroWe hane (IC 61.1-n
If arry W Na �e5dentW sNMwe n Ne WM not excee0'ug am (1) aoe tha[ trnm�Wiately s Ms Nat snucwre is used m pmduca Imm�a, desa3e ihe use aM porGOn
of ine rry unTaed m pradum
�G-/a-o3- � -x�o. ��-���
�.. . .: . .
Counry To.mship Counry ' Towrtship
I hereby certify ihe above stetements are true, cortect and complete. Sgnamre ot �
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PdAress (number and shee{ dry, sta7e, anO LP potle)
/9 � r .�O � i� ' ia.o N�/'7(a70
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Land not e:ceeding 7(om!) aue immediatety �'"'` "'`5`��-� '�� `
1 � a:.��T��+''fi'+x u ��_F �a�
surraundin resldentialim mvements. � � F
Kr:K_r. i�c��
Other land (2) ����'�P�,�,.fw,`
Total land (Iine 1 plus line 2) (3) �
. s s� S'a=�'a'H
Rwidentlal Improvements or Mnuatly �Iling (4) ���,�t4`�z,��'���irr�� : N�
0.sscssM Mobile / Manufactured Home Gare e �`��''�� ��M'���,�
9 is) ct"�!'.P�1`. } .hr e�,'�izim.
ONer Improvemenb (6) � �.�,,;�'c._� �'4n��
Toql improvemenb (line I Nloagn Itne � (7) �
Total value (Ilne 3 phs line n (8)
I hereby certify the above is W e, cortect, Sigretura af Assessar Date signed (montn, day, yea�
and complete.
VaifY�9 actim - Sigretura of f�uditw Date signetl (month. daY, yea� ,
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20 _ pay 20 _ Lesser of 60% of the assessed value of the homestead or 545,000
NWw9hsfaM6g anY oNer pmeisbn, fhe sum W Ne dedtdions proMCd in IC 6f.7-72 fa a mob,7e lar+ie Nai is S
rrof assassed as real property a fo a menuleGUied haro Net is nof essessed as real poperty may rro1 eroaeC '
oneJial/(iR) W Ne assessed refue d Ihe mobile home or manuFaGUrad f�arie.
Sigriahue of NMrtnr . Dace signed (rtronfh. daY. YTa� .