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CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD if SUPPLEMENTAL DEDUCTION
3 State Form 5473 (1112 16-09)
Prescribed by the Depanm rid of local Govemmem Fi ance
INSTRUCTIONS: See navetse side for filing instructions.
FORM YEAR
HC10
F LED
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CERTIFICATIOIS STATEMENT
I (We) V certify that Ir(17n led as my (our) principal
place of residence or am (are ying the following described operty for which a Hom ead mperly Tax�taTda uc I is hereby claimed
under conti on the date this plication is filed, (date of filing
❑ I (We) own ❑ Am (are) buying under recorded contract GIBSON COUNTY AUDITOR
❑ 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
Name t kg name)
Social Skaudy number ct
digts)
/ Itification /
Name da'Imani'
(legal name)
Social Security (lasr five digRs) Drivers license 1 Identifcadon / Other numbp,�., Issuing 3at�
of daimsnts spouse (last five digits)
/
CONTRACT •••
If buying on contract, Fee Simple owners name
Recorders office where contract is recorded
Record number Page
PROPERTY DESCRIPTION
Township
Taxlg district (dry, town, to
P nu r ////••��
Legal desoripptionn
Is the property in question:
� � W
• 26 If _oo /
I property AnaPy assessed rtpWe home (IC 6f. f -7)
If any portion of the residential structure or the lard not exceeding one (1) acre that Immediately surnotind§ that structure is used to produce Ircorra, describe the use and portion
of the property utrT¢ed to produce Income.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES
County Township County Township
I hereby certify the above statements are true, correct and complete.
Sljnatu ofd
Ad Or
Address (number and steer, 2 state, a ZIP code) .
D S S
ASSESSOR r AT 100% . '
L.UE
Land not exceeding 1 (one) acre immediately 1 'A,•;>.zF'14�ifii -�
•s.'r.'.,
surrounding residential innimovemen ts. O _ s.-� T5- '-
Other land
(2)
Total land (line 1 plus line 2)
(3)
Dwelling
(4)
9. ' N
Residential Improvements or Annually
Garage
(5)
Assessed Mobile 1 Manufachrred Home
Other Improvements
(6)
gg�;'.
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(8)
I hereby certify the above is true, correct,
Synahue of Assessor _
Date signed (month, day, year)
and complete.
Verifying action - Signature of Auditor
Data signed (n"dh, day, year)
STANDARD r r
20 _ pay 20 Lesser of 60% of the assessed value of the homestead or $45,000
Notwithstanding any other provision, the sum of the dedurrions provided in IC &1.1 -12 to a mobile home that is
$
not assessed as real pro rfy or to a manufactured hone that is not assessed as reel property may not exceed
on N(f of N a value I fhe mo6de home ormanufadured home.
S' o
Date sign ed�mon , d-Ay"` / )f) —I
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