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Z . STANDARD/SUPPLEMENTAL F! I '���
5." .6-' -• State Form 5473(R12/649) HC10•
= ! Prescdbed by the Department of Local Government Finance - L . ! • W.201
•INSTRUCTIONS:See reverse side for filing instructions. ..a.
II 9 CERTIFICATION STATEMENT
11 - . y.. certify that I(we)occupied as my(our)principal
place of residence or am(are)buying the following desczi I property for which a Homestead Property Tax Standard Deduction is hereby claimed
under contract on the date this application is filed, (date of filing):
(We)own ❑ Am(are)buying under recorded contract
AD
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
CLAIMANT'S INFORMATION
Name otl name) 1•.5)
Name of claimants spouse(legal name)
Social Seariy number of dahnant's spouse(last five dgits)I Drivers license/Identification I 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
County Township
or Tr district( ' ,town,township) -
Parcel number I Legal desolation Is a perry in question:
a L - b'-k'a5 -ID ` -ODb.R �r� -&0 al property ❑ Annuaay assessed nubile home(IC 61.1-7)
alIf any portion of the residential structure or the land not exceeding one(i)acre that immediately surrounds at structure is used to produce Income,describe the use and portion
of the property unload to produce inoon-re.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES
County Township County Township
I hereby certify the above statements are we,correct and complete. S, igpatu dai t ..r � ,1
Address(number and . lT/J /_�/ di/c_ OC/• `['/'�_ _ _.. __
1, stare,and ZIP ' ,
ASSESSOR USE ONLY I TRUE TAX VALUE i"AT 100°/OFATTVE I HOMESTEAD
VALUE AD I NON- VALUENTIAL
Land not exceeding 1(one)acre Immediately •a-'-v -:r• "6A "'fi`=2' tai.- .
surrounding residential improvements. (1) tiz;,. '`'£_,(4;'5g ..s�^ ->'>;4'
Other land (2) ..14 -- -
L i_
Total land(line 1 plus line 2) (3)
Residential improvements or Annually Dwelling_ (4) .c" - If
Assessed Mobile I Manufactured Home :'t'tA/:1i .t�.t�Sr.,,��.v, k�°f.
Garage (6) ', i7.,:a�S. a-^-.• .41/kYbis7tri,S
Other improvements (6) `-WZ
•
Total improvements(line 4 through line 6) (7)
Total value (line 3 pits line 7) (8) •
I hereby certify the above is true,correct, Signature of Assessor Date signed(month,day,year)
•
and complete. .
Verifying action-Signature of Auditor Date signed(month,day,year)
IIIII STANDARD DEDUCTION ALLOWANCE
20 pay 20 Lesser of 60%of the assessed value of the homestead or$45,000 w
Notwithstanding any other provision,the sum of the deductions provided in IC 6-1.1-12 to a mobile home that is $ �\
not assessed as real property or to a manufactured hone that is not assessed as reel properly may not exceed
one-half(1/2)of the assessed value of the mobile home or manufactured home.
Signature of Auditor Date signed(month,day,year) '