Homestead_Johnson (2)CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD / SUPPLEMENTAL DEDUCTION
State Form 5473 (R1216.09)
'O Prescribed by the Department of Local Government Finance
INSTRUCTIONS: See reverse side for filing instructions.
F1
AUG 0 5 2011
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CERTIFICATION STATEMENT
I'(We) certify that I (we as my (our) principal
place of resIdence, or am (am) buying the following described real property for which a Homestead('Pi Wsi d ffis hereby claimed
under contract on the date this application is filed, (date of filing):
,t
•�N (We) awn ❑ 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
.
If buying on contra0. Fee Simple owner's name
Recorders office where contract is recorded -
Record number Page
PROPERTY DESCRIPTION
County
Township
Taxing district (city, own Ipl
Pal number
ail
Legal description
Is the pope a question:
C! D -a c0- 0
3 • abs -CY7
eaI 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 surmurMs that Stnxture is used to produce Income, describe the use and portion
of the property utilized to produce income.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES
County Township County Towrehip
I hereby certify the above statements am true, correct and complete.
Signature o
drew (number and street, dry/u, sslatto,• and LPcode) `
,%
7 TS� �+ rO
ASSESSOR • r • r NON-RESIDENTIAL
AT 100% OF TTV I VALUE VALUE
Land not exceeding 1 (one) acre Immediately
surrounding residential improvements.
Otherland
()`
Ak
V�41
Total land (line 1 plus line 2)
(3)
Dwelling
(4)
r.. ..
i• la~'��4, rg•'t iv" r
�:•' tin- 'r'�si•u Yi;'3
Residential Improvements or Annually
Garage
5
Assessed Mobile I Manufactured Home
Other Improvements
6 -
k c.
�•"��� �`
Total Improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(6)
- I hereby certify the above is true, correct,
Signature of Assessor
Date signed (month, day, year)
and complete.
Verifying action - Signature of Auditor
Data signed (month, day, year)
STANDARD • r
20 pay 20 _ Lesser of 60% of the assessed value of the homestead or $45,1)()0
NamorhstarNirg any otherprovision, the sum of the dedut bons provided in IC 6-1.1 -12 to a mobr7e home that is
$
not assessed as real property or 10 a manufactured horns Nat a not assessed as real property may not exceed
one -hatl (7 ) of Me assessed value of the mobile home or manufactured hone.
Sigma
Date signed
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