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STATE MEM51569(RI/I-09) TREASURER FORM TS IA
APPROVED BY STATE BOMO Cf ACCCCATS.1tt19 PRESCRIBED BY 19{E DEPARTMENT OF IPGL GOVERNMENT FINANCE C6-1.1-ll-9.1
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 sue city,state,and ZIP code) •
AO 7 cin 7 C97 °
State Parcel Number _
•R el • a - a03 - 003 . 1 to 5 - 0 )-S j
PART 2:TAXPAYER INFORMATION
Owner First Middle Last
f
' Mailing Addr ( ber and street,city,state,and ZIP code) ` Et Same as property address
D . 41 553 ` /1 ✓,, � �rn�, ding 7 & 7v
Spouse First Middle Last
Mailing Address(Number and street,city,state,and ZIP code) n 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)
Sm,
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
PART 4:ADDITIONAL INFORMATION
I - I
MAY 2 4 2014
GIBSON COU I Y AUUl1 UP%
INSTRUCTIONS