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" CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD I SUPPLEMENTAL DEDUCTION
6 State Form 5473 (R121609)
'O ,•� Prescribed by the Department of Loral Government Finance
INSTRUCTIONS: See reverse side for filing instructions.
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CERTIFICATION STATEMENT
I (We) : I Or certify the ) occupied as my (our) principal
place of residence or am (are) buying the following described real property for which a Homeste hereby claimed
on the date this application is filed, (date of filing): GIB30N CO(U/NT
AUDITOq
[WIcontract
de
[t (We) own ❑ Am (are) buying under recorded contract ,Y
❑ Am (are) entitled to occupy as a tenant - stockholder of a cooperative housing corporation
Have a beneficial interest in the trust or the right to occupy the property under the terms of a qualified personal residence trust .
INFORMATION
Name of :ant (legal name)
m�-
'
Social Security number
- '
Social Security number of claimant's spare (last five dg ls) Driver's license I Identification /Other number Issuing State
of claimant's spouse (Iasi rive digits)
CONTRACT ••r
If buying on contract. Fee Simple ovmers name
Recorders office where centmcl is recorded Record number Page
PROPERTY
' b
v/y y1'n, y \ash
T W pQ Taxug ;( 1 G I O /N rp) -
o
Parcel number
Legal description
Ali
Is trhee p,�roperty, in question: -
6 . Q . Q 6 Co
- N S�
2 heal property ❑ v nuagY assessed rtnbfie home (IC i1.1 -7)
411f
si ounds that structure is used m produce income, describe the use and portion
any portion of the residential structure or the land not exceeding one (1) lq m
of the property utirmed to produce income. ' i
PROPERTY
County ship _
County Tavnship
-
I hereby certify the above statements am true, correct and complete.
Si�natare o nt
(Ndra�1 r�(• mbe�q streRt,Frry. slatC Cry
if ��� O (�•ILVI (_ 1
ASSESSED VALUE HOMESTEAD NON-RESIDENTIA
AT 100% OF TTV VALUE VALUE
Land not exceeding 1 (one) acre immediately
surrounding residential improvements. (1) Orj2 �e 7-k'"� 7,+s3 #LSY.e
+ace:
e tTS
Other land
(2)
n
Total land (line 1 plus line 2)
(3) a 3 6 O
Residential lm movements or Annual
Dive
(4)
Assessed Mobile I Manufactured Home
Garage
�j
(5)
q-i
Dot
-4.Z
Other improvements
(6)
Total Improvements (line 4 through line 6)
(7) ga
Total value (line 3 plus line 7)
(8) 11 (o C)
1 hereby certify the above is true, correct,
Sg re °IASSess°
Data signed (month, day, year)
61—.25-61
and complete.
verifying action - Signame of Audimr 47
Data signed (month, day, year)
20 _ pay 20 Lesser of 60% of the assessed value of the homestead or $45,000
Notwithstanding any other provision, the sum of the deductions, provided in IC 61.1 -12 to a mobile Mme that is
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not assessed as real pmperty or to a mares /artured hone that is net assessed as Waal property may nor exceed
wavy ( ) of the assess valu f the mobil° hone or mranufadured home.
Sigma o i�
Date -
ned (n fh, day, yea
( -1-1