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CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD / SUPPLEMENTAL DEDUCTION
S State Form 5473 (RI2I6-09)
S Prescribed by the Department of Low] Government Finance
INSTRUCTIONS: See reverse side forfiling instructions.
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DEC 2 9 Zulu
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CERTIFICATION STATEMENT
I (We) certify that I (IoGwpied�uisrgj� (our) principal
place of residence or am (are) buying the following described real property for which a Homestead Property 7 x_S �o,n��,�-t�vuc�oIt �x rmed
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under contract on the date this application is filed, (date of fili)"�
ng):
❑ I (We) own p Am (are) buying under recorded contract
❑ Am (are) entitled to occupy as a tenant - stockholder of a cooperative housing corporation
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a qualified personal residence trust
INFORMATION
Name ot/ 1'J�gn (legal name)
Social Seaviy cumber of clamant (last five dgE)
Driver's fcemse I identification I Other number
Isw'vg Sp{e
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of Uaimant (last five
✓
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Name W is (lapel name)
Social Security, nu of mant's spouse last five digits) Drivers license I Identification I Other Issuiq Sta
of claimant's spouse (last rive digitsl
CONTRACT RECORDED
If buying on contras, Fee Simple owners name
Recorders ofiw where contract is recorded Record number Page
PROPERTY DESCRIPTION
County '.
Township
Taxig distris (city, town, township)
Parcel number
Legal description
Is the property in question:
❑ Real property ❑ Annually assessed mobile home GC 61.1 -7)
If any portion of the residential smarm a or the land not exceeding one (1) acre that immediately sumwnds that strumre is used to produce income, describe the use and portion
of the property utdaed to produce Income.
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PROPERTY OWNED BY
County Tavnship County Township
I hereby certify the above statements are true, correct and complete.
5 re of aimant
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Address (number and street, CtN swe , and Zip
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ASSESSOR ONLY TRUE TAX VALUE ASSESSED VALUE . r
OF TTV
Land not exceeding 1 (one) acre Immediately Ali �%'i3^c
(�)
surrounding residential improvements. k -c•9"�
Other land
(2)'aE,-s$°
+,�
Total land (line 1 plus line 2)
(3)
Dwelling
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4
( )
.f�
trsSr� .4 x'ty�sx <�?xt,FS'txt
Residential improvements or Annually
Garage
MM?
Assessed Mobile I Manufactured Home
Other improvements
(6)
Total Improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(8)
I hereby certify the above is true, correct,
Signature of Assessor
Date signed (month, day, year)
and complete.
Verifying action - Sgnatim of Auditor
Date signed (month, day, year)
STANDARD DEDUCTION ALLOWANCE
20 _ pay 20 _ Lesser of 60% of the assessed value of the homestead or $45,000
Norwilhstandig any other pmvWon, the sum of the deducdwrs provided in IC 61.1 -12 to a mobrite home that is
$
not assessed as real property or to a manufactured home that's not assessed as real property may not exceed
one-half (1/2) of the assessed value of the mobde home or manufactured horse.
Signature of Auditor Date signed (month, day, year)
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