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f ..__. CLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR
-. STANDARD /SUPPLEMENTAL DEDUCTION HC70
State Form 5473(R12/6-09)
Prescribed by the Department of Local Goverment Finance �1
INSTRUCTIONS:See reverse side for filing instructions. - t RD
CERTIFICATION STATEMENT
i
I(We) MIFINI1,151WinPll certify th�il/( pied y my(our)principal
place of residence or am(are)buying the ollowing descn.ed real property for which a Homestead Property Tax tai' eduction is hereby claimed
under contract on the date this application is filed, (date of filing): .
❑ I(We)own ❑ Am(are)buying under recorded contract ��/Jt�Y�l
❑ Am(are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation rliPSON COUNTY AUDITOR
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a quali le personal residence trust
CLAIMANT'S INFORMATION
Nam' .- -nt y.'al - m
l
So®I Security number of daonant
(let dig ) Drivels license/Identfication I Other number Issuing Slate
- - - - _ 'v
Serial Security number of claimant's spouse(last five digits) Drivers license I Identification/Other number Issuing State
of claimant's spouse(last five digits)
CONTRACT RECORDED
If buying on contract,Fee Simple owners name
Recorders office where contract is recorded Record number Page
PROPERTY DESCRIPTION
Coon ir Township Taxing Ms.'. ( ,/wn, township)
11 IS A7
Parce/nl rwrtf�L./[ y� /y� Legal description Is.dre orooerty in question:
pop"_t / 3 co- Col- 0/9-pas LhjHCti)val property ❑ Annually assessed mobile home(IC 6-1.1-7)
If any portion of the residential structure or the land not exceeding one(1)acre that Immediately surrounds that structure is used to produce iMourne,describe the use and portion
of the property utilized to produce income.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES
County Township County Township
I hereby certify the above statements are true,correct and complete. Signature of claimant
Address(number and street,nay,state,and ZIP code)
- *53 E 900 S . 4 bs-1 W ' r 417u39
I I ASSESSED VALUE I HOMESTEAD I NON-RESIDENTIAL
ASSESSOR USE ONLY I TRUE TAX VALUE I AT 100%OF TTV VALUE VALUE
Land not exceeding 1(one)acre immediately 'yF ::_ r
surrounding residential improvements. (1) i^l:k7 .tt,>�4sz
intert "
Other land (2) FzYv' i
rr ; > ,.,r:
Total land(line 1 plus line 2) (3)
7
. Dwelling (4) -h-.,,inx•eta'�r.S .AtWitTx•a :n
• Residential improvements or ed Homy s _ - _`5 •
Assessed Mobile I Manufactured Home ,,
Garage (5) .Yr� iriTk dS,„ :Fr " sSsP:.a_e
Other Improvements (6) ,},.,,y,,: ! +4'.,x:
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 Data signed(month,day,year)
and complete.
Verifying ardion-Signature of Auduor Date signed(month,day,year)
STANDARD DEDUCTION ALLOWANCE
20 pay 20 Lesser of 60%of the assessed value of the homestead or$45,000
Notwithstanding any other provision,the sum of the deductions provided in IC 8-1.1-12 to a mobile home that is $
not assess-•as real property or to a manufactured home that is not assessed as real property may not exceed
one-half( o e assessed value of the :home ormanufactu
Sig tore.r • --home. _ k t)"SN r ' i Date signed(month,day,
1/4 41 f13 -1.1-