Homestead_Smith STATE FOLK 53549 I:V/1 TBFASIIRR FORM TS IA
APPROVED BY STATE BMQDCc ALLTNYTS,NA - PRE5CR®FD By TEE DEPARTMENT OF LOCAL GOVERNMENT FINANCE C 6-1.1-_4-I
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 I: PROPERTY INFORMATION _
Property Address(number and street,city,state,and ZIP code)
030 C 525/o H (h& t 41 Q40
State Parcel Number FILED
aG9-oa-ss - Ogg- ODD N 883 -018
SEP
2266'.2011}3
GIBSON COUNTY AUDITO;
PART 2:TAXPAYER INFORMATION -
Owner I First Middle Last\+�_
Mailing Address(number and street,city,state,and ZIP code) 2�ame as property address
11/Security Number(last S digits) Drivels License/State ID Number (last S digits) Other(please specify in Part 4 below)
. 6 5.ta, Casa°
Spouse First Middle Last
Mailing Address(Number and street,city,state,and ZIP code) [] Same as property address
Social Security Number(last S digits) Driver's License/State ID Number (last 5 digits) Other(please specify in Part 4 below)
sou
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 Signature Date Telephone
q-0s- L3 ($ 1a)gg1
Spouse Signature / Date Telephone
( )
PART 4: ADDITIONAL INFORMATION
INSTRUCTIONS
MVP p-5 \