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"'" CLAIM FOR HOMESTEAD PROPERTY TAX
a, ._ � STANDARD / SUPPLEMENTAL DEDUCTION
Stste Fortn 5473 (R72 / 6-09)
S Y PrascribM bY the Departmem of Local Gove inance
INSTRUCTIONS: See reverse side
S�/-�'7 89- 30 �f.�
; ; � � ''�,�5 �
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I(We) (L,l.((Aivv� O� /T!/-LCCil/l/ certiry that I(we) occupied as my (our) prindpal
place of residence or am (are) buying the following described real property for which a Homestead Property Tax Standard Deduction is hereby daimed
under conVacl on ihe date Ihis applicauon is filetl, � (date o/filing):
� I(We) own ❑ Am (are) buyi� under recorded convact �
❑ Am (are) entitled to occupy as a tenant-stockholder of a cooperadve housing corporation
� Have a benefidal interest in Ihe Wst or the right to oCCUpy Ihe property under Ihe tertns of a quaiified personat re5idence W5t
of tlaimant (Wsf frve dgits)
Name o( dac�wrt's spouu (legal nanej
Sotlal Sewriry m�mCa of tlaimanCs spouse
ol daiment's spouse (last �ive
If buying m mntraG, Fre Simple oxnels rame
RemNefs otfxe where convecc a remrtleU
Iswuig Sa;e / _
k� �
Recortl numbnl
���y Township Ta�sg tlistritt (riry, Io township) _.�
( [%L N '��
Pa�cel number �gal tlesaip' /�1 s property in question:
� ❑ Real pmpr.rty ❑ AnnwVy a:sessed modle home (IC &1.1-n
If any portbn o( Na rnsi0ential swcwra or Ne rM nol exceeding am (7 ) acre that 6nmeCiacey surtounES Nat sducNre is useC co proEU�e incoma, EesaOe Ne use and portion
of the P�PP+�Y uhTaed m P�ure mmrtre. -
� -�i-3a -303 - �oo - y ��-oa �
Coumy
Twmship '
I hereby certiTy the above stetements are We, corred and complete. �
Address (num6er anC sUee; dry, stefe, and LPCade)
i z s�i F,.�- :,r� s so,�� o�,��ati„/ C
Laoa
Olher lantl
Total Wnd (line 1 plus line 2)
acre
Dwelling
Garage
Othu ImD��menb
Tofal improvemenb (Ilne / NrougAline �
Toql value (line 3 pl�s Ilne n
I hereby certify the above is We, cortect,
and complete.
Vaityifg a�on - Si9naNre al Niditor
(�)
(2)
(3)
�4)
(5)
(6) . .
��)
(8)
SignaII�ra of Assessar
Counry
r
20 _ pay 20 Lesser o( 60% ot ihe assessed value of Ne homestead or 545,W0
AbMdhstarNeg any ofherprovaion, the sumW fhe deduct+ms p�o�idcM in IC 61./-72 ta a mob0e home thal is E
not essesreC es reel propeily a lo e menufectured har» Nat is not essessed as real pioperty mey rial exoeed
anahaH (fllJ W Gre essessed rehm W Ne na0de fwmc a manulactureU hortie. .
unaORe of Auditw • .
Dace sgnetl
Y�7
Date signe0 (rnonlh. daY• Yea�