Homestead_Ellis (3) FORM HC 10 1979 To Be Filed in Duplicate
Prescribed By State Board of tax Commissioners
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT FF.Q -&AR 19 79
SEE BACK FOR FILING INSTRUCTIONS
/ier//9EL ' ? A4 S F- ah, certify that on the 1st day of-
Ø(we)
arch, 19_-77_., I, (We) occupied as our principal place of residence the following described real property for
which a Homestead Property Tax Credit is hereby being claimed:,
I, (We) ❑ owned -
❑ are buying .under contract
❑ have a beneficial interest in the taxpayer / /
Property Description in �is3So r/ �� County Zei/V/Tr /6rre'e Township
Taxing District (City, Town, Township): iyAzleToz✓ Co," -
Parcel Number or legal description shown on tax statement:
/4 /J7.,P 33 - / -/O '17 g
If buying on contract: Owners name (fee simple owner)
Contract recorded in Recorders Office - Record No. Page 1
If any portion of the residential structure or the land, not exceeding one (1) acre that immediately surrounds that
structure is used to produce income, describe the use and portion of the property utilized to produce income
Any other counties in which individual owns or is buying real property: County Township
plbhereby certify the above statement is true, correct and complete.
14tacas G P� � ¢ I Sox 1-/-so I-la ?Le-[&, 1,4 4-764-o
'Signature - Street Address City. State and Zip Code '--
Individual either owns or is buying under a contract that provides he is to pay the property taxes
on the residence, or has a beneficial interest in the taxpayer.
- FOR ASSESSOR'S USE ONLY -
True Cash Assessed Homestead
Value Valuation Valuation --
Land not exceeding 1 (one) acre immediately
surrounding residential improvements (1) Soo /00 /00
Other Land (2) — -
Total Land F I (3) Soo /00
Residential Improvements JUN Ig79 Dwelling (a) t-ra �����
Garage (5) ���� /¢t
����tit� —{� Total (6) 3 "9L SUS /6�
r Improvements AUDITOR (7) (�______
Improvements Line (6) plus (7) equals (8) (8) 3:7� ��
. -._.eby certify. the above is true. correct. and complete. I S 3 0
Signature of ssessor Date
- ACTION BY AUDITOR
Approved: S, q. " AT Date: MCI
STATE FORM S3SW(YJ161a) TREASURER FORM TS-IA
• APPROVED BY STATE BMRDOF ACCOUNTS.YM PRESCIUBID BY THE DFPARMEYT OF LOCAL GOVERNMENT FINANCE 1e 611-222.1
Gibson County Auditor IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS
101 N.Main Street lndisiduals anti married couples are limited to one homestead standard deduction.As the receipt of this deduction becomes
Princeton, IN 47670 more beneficial,there is more incentive than ever for homestead fraud.Homestead fraud causes higher tax bills for all;therefore,
HEA 1344-2009 requires taxpayers who receive the homestead standard deduction to verify that they am eligible to receive the
• benefit and to provide additional identifying information necessary to allow county government to boner 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.
PART 1: PROPERTY INFORMATION
Taxpayer Name Location Address
_ - - Ellis, Michael G/Kyle E
'l$tl1��® 9 2nd
Hazleton 855 FILE T IN 47640
Michael G/Kyle E j('( 10 2011 II 10111-111111 III III 11 IIIIII1111111 v1IIlII]11111111111 II IIIIIIIIIII III IQ II
509 E Second ST
HAZLETON IN 47640
X11111111111111111111111 11il1llllllt II IIII1�IIlll1lt1111111 State Parcel Number Legal Description
GIBBON COUNTY AUO TTO�R 26-02-59-033-000.117-018/ PT MD 33 1-10.37 AC
.3
This form MUST be returned to County Auditor's office.
Please do NOT send this form back with your tax payment to the county treasurer.
Fuse Middle / F Last
1�1 �(A� C EL.CI--
Mailing Address(number and street,city,state,and ZIP code) 111 Same as property address
bog Sj S-Qod,u61 k/AZL&JODJ, j -7 coy D
Spouse First Middle Last
fi 'I±( reA),0a ALL', c
Mailing Address(Number and street,city,state,and ZIP code) 10 Same as property address
Cu q at sr a ero tJ i, )-I AZ L ET-0 f\i _)v LI R o
PART 3:CERTIFICATION
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 I Signr ` Date ,` ' //
•