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4 CLAIM FOR HOMESTEAD PROPERTY TAX FORM
CREDIT/STANDARD DEDUCTION HC10
State Form 5473 (R215 -92)
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INSTRUCTIONS: See reverse side for tiling instructions.
CERTIFICATION STATEMENT
I (We Erimb certify that on the 1st day of March, 19
1 (We) ied as our principal pla of residence the following described real property for which a Homestead Property Tax Credit is hereby claimed:
I (We) owned ❑ Are buying under contract
�iave a beneficial interest in the entity that is liable for the property taxes on the property and that owns the property or is buying nderfacnntract.
1X1 11 II r1_A • It N
CONTRACT RECORDED 1 x.r 0
vnrx. J IJJJ
If buying on contract, Fee Simple owner's name
Recorder's office where contract is recorded ,RQGOld.`uyberf', 4 Rage
AUDITOR
' PROPERTY DESCRIPTION
County
Township - -
Taxing district ( dry, to ow ip)
NON-RESIDENTIAL --
VALUE
a e,(Wr r
U
Legal description _ , ^3q
r /
It any portion of the residential structure or the land not exceeding one (1) acre that immediately surrounds that structure is used to produce income, describe the use and portion
of the property utilized to produce income.
t.
ASSESSOR USE ONLY
TRUE TAX
VALUE
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES
County
NON-RESIDENTIAL --
VALUE
Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
(1)
Other land
(2)
I hereby certify the
hour? n s ar lr e, correct and complete.
Signature of claimant
�ress (num r a
�•eet, ly stale P
7
e
ASSESSOR USE ONLY
TRUE TAX
VALUE
ASSESSED
VALUE
HOMESTEAD
VALUE
NON-RESIDENTIAL --
VALUE
Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
(1)
Other land
(2)
Total land (line 1 plus line 2)
(3)
Residential improvements
Dwelling
(4)
Garage
(5)
Other improvements
(6)
Total improvements (line 4 through line 6)
(7)
Total value (line 3 pbs line 7)
(S)
'
I hereby certify the above is true, correct, and
complete.
Signature of Assessor
Date signed
Verifying action - Signature of Auditor
Date signed
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SWL HAM!Mt.IR2t W I TBEANIID.PORN IS-IA
APPROVED BY SEx1E WARM*YY,EITS.! N rmr tBm BY TAE DEPARTNEW OF LOCAL 00%7llMNr/a FINANCE Ice-I.,-r-E.0
Gibson County Auditor
101 N Main IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS °
PRINCETON IN 47670 Individuals and married couples arc limited to one homestead standard 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 taxpayers who receive the homestead standard deduction to verify that they am eligible to receve the
benefit and to provide additional identifying information necessary to allow county government to better monitor homestead
• fling..This information will he kept conEdential and can only be accessed by authorized county officials.The Depannent of
Local Government Finance will use this information to create tads that will help county officials eliminate homestead fraud.
PART I: PROPERTY INFORMATION
Taxpayer Name Property Address
Embree, Jill K
3001 l:400 N
_ Patoka IN 47666
762
Jill K Embree
3001E 400 N State Parcel Number Legal Description
PATOKA IN 47666-9205
26-05-22-400-000.425-017 009-00425-00 PT SE 22-1-101.7391 AC
ltlltllntlt11ut11nt11nitlnu1r111uu1r1r11 11111111
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PART 2:TAXPAYER INFORMATION
Owner I First Middle Last
I I , I6 Em brew
along Address(numeer and itiret,eity.state,geed ZiP code)_ . I Same a;pmperiy
300 E Vac 14 P« Ka/ - N '! 7#61
Spouse First Middle Last
Mailing Address(Number and street,city,state,and ZIP code) Same as property address
Social Security Number(last 5 digits) Driver's License/State ID Number (last 5 digits) Other(please specify in Pan 4 below)
,CD s°tc n- .1 �-
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 I Signature /r ea Date
PART 4: ADDITIONAL INFORMATION
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