Homestead_Sporej
CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD If SUPPLEMENTAL DEDUCTION
State Form 5073 (R13/ 12-09)
yw Prescitti by the Department of Loral Government Finance
INSTRUCTIONS., See reverse side for fifing Instructions.
FORM YEAR
HC10
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•firw.`•u�k...i.'rL't1 ti.'�..�,3. ism. 3.. ��u'."} m, 1, 1' f3!'!, CERTIF; ICATION :STATEMENTa;`ti.'•:v''.r3z.:i.t
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nce or ?ere-by aimed
on the `
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■ Am (are) buying under recorded writract GIBSON COUNTY AUDITOR
■ Am (are) entitled to craoupy 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 residerim trust
■ Am (are) the shareholder, partner or member of the entity that owns the property.
_
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` �, ?ta•.tt1'�1.::..�.,a- .- .t�.?3�a x�#•t'.c �x:`TMir, gIMASINFORM ORMATIONy- ��4„ � '`8:.+te._.ao?v_FZ��`a.r�'�?.�i
��_ W-
number
Social Security of
. Other number
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TII£�"oCONTRACT_RECORDED(:..t_
its t party in question:
IfTReal voperty Annually assessed mobile home (IC 6-1.10
P_.X-�»�";xrg'rx_v4;�n` PRO RTY; OWNEDBI';;' CLAIMANTINOTHERCOUNTIES4 „;.#3,,A'_'_��.Y_,.,__,s,
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I hereby certify the above statements are true, mrrect and ocimplete.
WN 1 � e. ♦.
VALUEI aa ON- RESIDENTIAL ;
HiOyMVESTEAD' f.eSESSO
,Ni
?6y s- ti:•VAL'UE _�. ts'c:�,.
VALUEAT:100�Landn
Immediately
SU at Ina rovements.
Total land (line 1 plus line 2)
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I
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--
Residential Improvements or Annually
Total improvements (fine 4 through line 6)
Total value (line 3 plus fine 7)
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I hereby certify the above is true, correct,
and complete.
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f >r,1,8] _ _
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• 1 - 61% of the assessed value of the homestead or 111
not asiiassad as real property or to a mnutiectirad houre that is not assessed as real property my not exceed
wiaffI12) of the assessed value of ft arobAg hone or nrarrLdracturad home.
STATE FORM 5/569(RIB-la) TREASURER FOAM TS-IA
APPROVED BY STATE BOARD OF ACCOUNTS.2009 PRESCRIBED BY THE DEPARTMENT OF LOCAL GOVERNMENT FINANCE IC6-I.1-22-5.I
•IMPORTANT NOTICE TO`HONIESTEAD PROPERTYOWNERS
Individuals and married couples are 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
muses higher tax bills for all; therefore, HEA 1344-2009 requires taxpayers who receive the homestead
standard deduction to verify that they are eligible to receive the benefit and to provide additional identifying
information necessary to allow county government to better monitor homestead filings. This information
will be kept confidential and can only be accessed by authorized county officials. The Department of Local
Government Finance will use this information to create tools that will help county officials eliminate
homestead fraud.
PARTI:. Pi OPE' Y INFORMA ION
Taxpayer Name Property Address State Parcel Number Leal Description:
Gregory\V/Lacosta Spore 4778 N SR 65 26-05-57-105-000.301-017 PT MD 105 I-10 2.60 AC
PATOKA IN 47666 C-1
Complete and return to: I®h!Hn1FIEH UIRpn1RI®117®EIMIINIlfBtI11111®
GIBSON COUNTY AUDITOR, 101 N MAIN PRINCETON IN 47670 IIEt11L LI LL91fILL LIJI
PAR(2 T&YPAYER INFORMATION •
Owner I First Middle Last
eo\�- y w (�l e� cDCe
Mailing Address(nu and street,dt ,state and ZIP code) Same as property address
Spouse First Middle Last
C-c" f0. 5re-,
Mailing Address(nunfler and street city.state and ZIP code) I.I "ame as property address
• -
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 1 Signature Date
PART 4:ADDITIONAL INFORMATION • '
'PTT V TM,
• •IVUV Z LUlL
•
GIBSON COUNTY AUDITOR
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