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STATEFORM S]569Qn/]dn TREASURFA FORM TS-IA
ARROVFD BY STATE BWRD of AROU. A]W9 FRFtf]IIDmBY THE.DEPARTMENT OF LGLOOVFANF NT FINANCE IC 61.1-181
IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS
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 causes 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 indentifying 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.
PART 1: PROPERTY INFORMATION
Property Address(number and street,city,state,and ZIP code)
7 0 w P Pcua PT
State Parcel Number
a1-\ 1 - 0 \ - AiO3 - ooa . -735 - n 2
PART 2:TAXPAYER INFORMATION .
Owner I First Middle Last
�ho.rle s p k >( o n
Mailing Address(number and street,city,state,and ZIP code) ❑ Same as property address
—1 0 3, W re— S t Pcar ,J
Spouse First Middle Last
Mailing Address(Number and street,city,state,and ZIP code) El Same as property address
Social Security Number(last 5 digits) Driver's License/State ID Number (last 5 digits) Other(please specify in Part 4 below)
1
State
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 dedu 'e 'lawfully,he or she may be liable for back taxes and substantial financial penalties.
Owner I Signatu '� 1 Date a,, Telephone
� MAY' /2MA-
pouse Signature Date Telephone 1/ l ■
PART 4:ADDITIONAL INFORMATION
11. , = .-uol�on
INSTRUCTIONS
GAB
L. — — -- —
�, R ry� � CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
; � State Fortn 5473 (R4 / &00)
�.,.
� INSTRUCTIONS: See reverse side (or filing instr�clions.
FORM " YEAR
HC10 �
�� ��i�
I(VJe) l �/'N�-�CN C� "�`-Y"" N�'�-/ /� ���X--t'J /� qertify that on the 1s�c
G� / �
I(VJe) ocwpied as our prindpal place of residence the following desaibed real property for which a Homestead Propert�TaC.Gfe
❑ I(We) owned ❑ Are buying under contrect GIB� T�
�Have a beneficial interest in ihe entity that is 1ia61e for the property taxes on the property and thal owns lhe property or is buy
����r'�.t����.`�r::- '��'�,� _�'���CONTR/1CTnRECORDED�-.z-.i`�.�"�`..1.=„_.� ��,�'� .s:
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If buying on cantrac� Fee Simple ownefs name `� ` �
r .
Recordefs office where contraG is rnmrde0 . _ RecorE number
County Twnship
V
Pa number Legai de:
l -o a� 3S -o�
If afry pation of Ne rnsidenUal 5 WCture w Ne land �at
ot ihe property uLtaetl to proCUce income.
of March, 20
is q@reblr,da'vned:
acontrad.
PaBe
'�� ►-a-i_l � 1°� f�C
(1) acre that immediatey surrountls that svuaure is used to protluce inwme. describe the use and pMim
Counry Twvnship . County
I hereby certity the above statements are true, correct and complete. u�
�
A dreu numberandstreetd tafe,ZlPCOde)� �
2. Y �to-�,.� /�� n� . -,��,.__
F�
Twvnship
'" '4��,_�".-�',y',i2`�����3�'-_�'{s_��$TQNDARD�DEDUCTIONALLOWAIJCE���`u�'..��"��.�,�y�,;�'s`�,,,,,»°,�?"'y*'.��_
20 _ Pay 20 _
lesser of 12 Homestead
Valua6on or $6,000 $
S' t ofAuditw Date ' ned�—� ^/
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