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CLAIM FOR HOMESTEAD PROPERTY TAX FORM
CREDIT /STANDARD DEDUCTION Hc10
t J State Form 5773 (RS 110 -01)
Presimbed by the Department of Local Government Finance
INSTRUCTIONS: See reverse side for filing instructions.
YEAR
I (We) i l /T,C.f a . )A AA i /)N certify that on the e�l yst day of March, 20 uaMtd
1 (We) occupied as our principal place of residence the following described real prope for which a Homestead Property re4t ® hJ602daimed:
❑ I (We) owned ❑ Are buying under contract / /] /,
aHave a beneficial interest in the entity that is liable for the property taxes on the property and that owns the pil, t or i!- buy}ng u�er a cgr7uaco
NTRACT�RECORDED :.e. c''�"£ '�'.�€• ' ors' -r .^z.A�", = 'T���.."`n^' +<y','
If buying on contract, Fee Simple owners name
Recorders office where contract is recorded Record number Page
.'-,.+': �i�' siw' x4. Y',#•? sP. ROPERT, YAESCRERTION
County
Township
Taring district (dry, town, township)
P cel n bar
'W
L e ription (.J Is the property in question:
— '� 9 1 E ❑ Rest property ❑ Mobile Homo (I.C. 6-1.1 -7)
If any portion of the residential structure or the la not exceeding one (1) a a that Immediately surrounds that structure is used to produce income, describe the use and portion
of the property Wind to produce income. 31riu /5
�:'�=k'L.`'T"`_�;�ck ` ��- >�PROP.ERTY,OWNEDBYCLAIMANT IN'OTHER'COUNTIES Ors �r *�
County Township
County Township
hereby ce ' e above statements are W e, correct and complete.
S n o imam
' "a ss er` str fate, ZlP code) J
! 17 Z
s
' �`A SSOR E O' Y }
; STRUE TAXI
ASSESSED VALUE
;kHOMESTEAW
• NOWRESIDENTIAo" ri
�j�r
$
AT;t00Yo Or. V�
?f.?:s.VALUEza
Land not exceeding 1 (one) acre immediatetyY
Date signed
surrounding residential Improvements.
�`.1^
Other land
'yEr;x
Total land (line 1 plus line 2)
(3)
Dwelling
(4)
-� r
ME
a w ,'. ONE
Residential improvements
Garage
(5)
.im
Other improvements
(6)
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(6)
I hereby certify the above is We, coned, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
.:xrSiSTANDARD.DEDUCTION ALLOWANCE,. i.. a.' eifi.: a:',° ts�" `-s'.'_�E_'Fz..c- '.`.':7:,�,e'=
20 _ Pay 20 _
Lesser of 1/2 Homestead
$
Valuation or $6.000
Signature of Auditor
Date signed
L
stAtS FOOL 3.WIR UYPI TREASURER FRM:11A
MPPR[:EDDY STATE MM0.noF MAFTAANTS.Soo PPFSABrD BY IDE DEPARTMENT Of LO L GOVERNMENT FNA]CE ICA-I.6-L4A
10nty Auditor
1 N Main IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS f
PRINCETON IN 47670 Individuals and married couples are limited to one homestead nandaN deduction.As the receipt of this deduction becomes
more beneficial,there is more incentive than ever for homestead fraud.Homestead fraud causes higher tax bills for all:therefore.
HEA 1344-2009 requires taxpayer who receive the homestead standard deduction to verify that they are eligible to recehe the
benefit and to provide additional identifying information necessary to allow county goeenment to better monitor homestead
filings-This information will he kepi confdennal and can only to accessed by authorized county officials.The Depannent of
Local Government Finance will Ire this information to create tools that will help county officials eliminate homestead fraud.
PART 1: PROPERTY INFORMATION
Taxpayer Name Property Address
Devoy, David/Susanna
AI Dos 1-72D — \
Hazleton m 47640 (]
213 lY
David/Susanna Devoy
6831 N SR 65 State Parcel Number Legal Description
Hazleton IN 47640
26-05-01-200-002.758-017 009-02758-00 PT SEC 1 1 10 PT LOTS 4/5
. 43.224 AC C-1
^ r
PART 2:TAXPAYER INFORMATION
Owner I First' Middle \ I L Last
LLS -N N A — _ lie try / - —
--g A d d r e s s(number and strut,city,state,and ZIP code) �'Same as propenyud -
6-)SI 31 A!. 5+ R J 6 5 IcZle4on . Tltl 476 (/n
/
Spouse First Middle ' / Last
t
baVIQ a� beVOV
Mailing Address(Number and street-city,stale,and ZIP code) ® Same as propen_ addrtss
4 SS Af 5+ - red 65 Wa Jeglin IVO
•
PART 3:CERTIFICATION
Each undersigned certifies,under penalty of perjury.that the above and foregoing information is true and correct and that he or she is eligible to
receive the homestead standard deduction on this property. Each undersigned also understands that,by claiming additional homestead deductions
unlawfully,he or she may be liable for back taxes and substantial financial penalties.
Owner Signature Date
PART 4: ADDITIONAL INFORMATION
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