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_,f,a:.--; CLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR
• STANDARD/SUPPLEMENTAL DEDUCTION
State Form 5473(R12/649) HCIO
Prescribed by the Department of Local Govemment Finance
INSTRUCTIONS:See reverse side for filing instructions I 1: 111
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® ff CERTIFICATION STATEMENT
I(We) . H/kJ' __!-. / L !� certify that I(we)occupied as my(our)principal
place of residence or am(are)buying the following described real property for which a Homestead Property Tax Standar u2103 i2911113by claimed
unde ntract on the date this application is filed, (date of filing):
I(We)own ❑ Am(are)buying under recorded contract
❑ Am (are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation ac !���AI7/ �AUD TOR
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a qualified peg3brtat' icgLiklst
CLAIMANT'S INFORMATION
Name ofd 'mFn (1 gal came)
Name
of claimant's spouse pouse(legal name)
Social Security rumba of claimant's spouse(last five digits) Drivers license/Identification/Other number (swing 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 Taxtown,ing district(city,to township)
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a,/,l�L Pa nu'm)b�er �y� Legai d • Is the property in question
V-4--all - o -oo a 3 I l-o - , j _ ❑Real property ❑ Annually assessed nndle home(IC 6-1.1-7)
- If any portion of the residential structure or the land not: .,.-•. .one Mac
re that immediately surrounds that structure is used to produce Income,desabe the use and portion
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PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES
County' - Township - County Township
I hereby certify the above statements are true,correct and complete. Signature,...-dal ��
Add (number and„_- city,state,and ZIP code
} 2 •A . 9t . .. Z)/ a
I AAT E
ASSESSOR USE ONLY I TRUE TAX VALUE 0%OF TTVE I HOVALUEAD I NON-RESIDENTIAL
VALUE
Land not exceeding 1(one)acre immediately zy`Siatila 'r � •.r_{
surrounding residential improvements. • . (1) ,=a .-5' ::W''` _€.. ,.
�T
Other land (2)' `. °?.; ;. i fit' •
Total land(line 1 plus line 2) (3)
Residential Improvements or Annually
Dwelling (4) `e-.J. arig"�"sc�_5 s 141:1 eeis... ,-.
Assessed Mobile I Manufactured Home eii r i .4
Garage (5)
Other improvements (6) .01-4- .4s; l
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 Date signed(month,day,year)
and complete. .
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Verifying action-Signature of Auditor Date signed(month,day,year)
STANDARD DEDUCTION ALLOWANCE
20 pay 20 Lesser of 60%of the acu•csed value of the homestead or$45,000
Notwithstanding any other provision,the sum of the deductions provided in/C 6-1.1-12 to a mobile home that is $
not assessed as real property or to a manufactured home that is not assessed as real property may not exceed
one-half(fr2)of the assessed value of the mobile home or manufactured homy
Signature of Auditor Date signed(month,day,year) '
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