HomeMy WebLinkAboutHomestead_Hadley (2) STATE FORM 51569(R211-09) TREASURER FORMTSIA
APPROVED By STATE BOARD ARWMS,2029 PRESCRIBED BY THE DEPARTMENT OF LOCAL GOVERNMENT FLNANCE IC6-2.222-A.I
IMPORTANT NOTICE TO HOMESTEAD PROPERTY-OWNERS
Individuals and married couples are limited to one homestead standard deduction. As the receipt of this i
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 c e) �
r
State Parcel Number
a to- // -O / - /iO - on 60a -0Q F/LED
JUL 9 2014 j.
' PART 2:TAXPAYER INFORMATION •R
Owner I C_�–}Q'}�—�\(\�' First . Middle s( Last
\
Mailing A�ss(number and street,city,state,and ZIP code)/` n Same as property address
to ao N C7DA \-)%5 k1 1 t
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)
State
PART 3:CERTIFICATION F
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 unl awfully,he or she may be liable for back taxes and substantial financial penalties.
Owner I Si tur / 7 f Date
I f
INSTRUCTIONS
CLAIM FOR HOMESTEAD PROPERTY TAX � venR
a_ 1' STANDARD/SUPPLEMENTALDEDUCTION FORM
Sa:e Fc�m Sa]� �Rf S I S14J HC70
���' PresmMEEytheOepaNnentofLaalGOVemmeniF'vunce
INSTRUCTIONS: See reverse v0e lor hting insfructions.
NOTE: T¢I¢pfwnB, Soclal Secunry, tlrive(s lirenu, s1atB idenlificetbn aM (ederal idenli;�cafibn num0ers are mnfitlen✓al .1 37. �
I(We) - .� certiry ihat I(we) pi -
place of residence or am (are) buying Ne �ng described real property under contred for which a Homestead Property Tax Staridard
Deduc6on is hereby daimed on Ne tla:e is appGrafion is signed, (dafe o/stt2tleh tNJqh�C
fVV Y 1 J LU J
�Own. ❑ Am (are) buyinq under recorded wntract. �i
❑ Am (are) entltled to occupY as a tenanbstockholder of a coopera:ive housing wrporation.
❑ Have a benefidal interest in Ne Vust or the nght to occupy the pmperty under Ihe terms of a qualifed p st.
❑ Am (are) the shareholder, partner, or member of ihe entity that owns the property. GIB$�N C
R
Narne of daunam (ICgai nartre) ieleqwne nienEer ct W:mant f
b '. �.dle �
,( ol
Sil� I
Hame W damant s spouu (kgel name) '
I
NA �
SotlalSew�itynumberofGa'unantsspouse(W9frveCyh) Omer'sfunzelbeee�v4m/b.�ernumDer Iss�mg5a:e �
ot aamwnrs srouse (rasr m�e eqas� I
It dry"ug m conraq Fee Svnqe owneh name �
Remtdefao�cexTeremnVaCizrerwEetl RemEnumCC Paga I
Coun:/ TonnslvC , Tarv+9 E's4in 1�Y. furrt lm.rWp) i "
IbS�ti o 't�n -f n
Par¢Imanher LepalGesaipion IlaNepropM.yinpues'sn:
'�'� �" . iO�cZ'� CkyReal P�ce�:Y ❑ Mn�aN usess� moWe twme I i bt.t-]/
tl a�ry pof.im o( Ux resitlem.ial sSVCture w iM IanC �rot exceeEig one (t) aae Uut vn-icCU:ey smw�Ma Taf xeuGwe is �sM ro poEUrn vmrt�e. EesuiEe Ne use antl �poNOn
o( c�e aox�:r vazea m a�ua vucnx. . I
�'r. �y.+^eT�T•�c Is da'u:ant rantlng a homes',eaG?
❑ Yes ❑ No I
syiu:me a aximars ' I
1 here6y certify the above siatements are true, mrtect, and comple:e. � '
PaCrtss M nrraa (numDer arp s4ee�, rsy, 5a:e, W LPmCe) ACtlress of no;eE �wnezmC, f any (num�an0 sreet, ory, 5aza, erM LPwde)
T IOaO old N� `IIM1I,�rincz�on � y�.� I
Land not exceading one ('I) acre ImmedWtety I(�) I
surtounLin resitlentlal im rovemenb
Other land I R) '
Total IanA (line 1 plus Iln¢ 2) (3) � I
Residantial improvemanb or Dwe�ing I(<)
Annually Assessetl MoElle I
Manuhcturatl Home Garege I (5) '
Oiherimprov¢ments (6) I
Toml improvoments (line 4 Nmugh line 6) Q) I
Todl value (line Jpl�s line l) (8) I
Iherebycerti(ytheaboveisWe,corr¢c4 SgiumreofAssessor Da'ssigree(mWqCagyeap
and complete. - �
vaity'uq acicai - Signame otPUal:w Oa� sgnea (rtm:n. aay. ia�
I20 _ pay 20 _ Lesserot 60% of Ihe assesseE v�ve of Ne Mmes;eatl w 545,000 I
AblwifistaMing any otherpmWSion, Ihe wm ol (he tletlucfions provided in IC bi.l-72 ro a mobila frome 5
Naf is not essassed as real properry w ro e manufaUured lame Nat is rrof assessetl as real property may
rmf e+ceetl one-haX (1R) o! the a.isessed velue ol the rtaW7e home wmanu(aGumd hame.
Sigfuaire o(AUd'ar Da:^ zg M(r.ve/L �Y,Yee� I
OISTRIBUiIOH: OnB�� -�un.y AuCM1w, F0e9amped Cop) - Taz{vyn