Homestead_ChamberlainiCLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT /STANDARD DEDUCTION
•i State Form 5473 (8215-92)
INSTRUCTIONS: See reverse side for filing instructions.
FORM
HC10
YEAR
CERTIFICAT4PN STATEMENT
I(We) J94-0 ertity that on the 1 st day of March, 19_
I (we occupied as o nncipal place of residence the following described I property for which a Hom to d Property Tax Credit is hereby claimed:
1 (We) owned ❑ Are buying under contract - ,' '`i � 1 • f r
-Rt�
❑ Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns the property or is buying u ndt er a contract.
CONTRACT RECORDED I11 �+
If buying on contract, Fee Simple owners name
/
Recordels office where contract is recorded '
Record number. ' lPage
PROPERTY DESCRIPTION
County
Township -
Taxing district icily, town, township)
Legal description
If any portion of the residential structure or the tend not exceeding one (1) acre that immediatety surrounds that structure is used to produce income, describe the use and potion of
the property utilized to produce income.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
County Township County Township
Signature of claimark
the are true, correct and complete.
:reby certify above statements
Address (number and street, city, state, ZIP code)
1 Oct W M 1 w o I w 7fo (�
ASSESSOR USE ONLY
TRUE TAX
ASSESSED
HOMESTEAD
NON- RESIDENTIAL
VALUE
VALUE
VALUE
VALUE
Land not exceeding 1 (one) acre immediately
(1)
surrounding residential improvements.
Otherland
(2)
Total land (line I plus line 2)
(3)
Dwelling
(4)
Residential improvements
Garage
(5)
Other improvements
(6)
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(8)
I hereby certify the above is true, correct, and
Signature of Assesor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
STANDARD DEDUCTION ALLOWANCE
19_ Pay 19
Lesser of 1/2 Homestead
Val Ition or S2,000
Signature of Auditor -
Date signetl r,
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.clAtE FORT'e*IR:/fdl IREANaflt FORM:S-IA
RU IMPORTANTTNOTICETO HOMESTEAD EP PROPERTY OWNERS
. Gibson County Auditor
101 N Main
PRINCETON IN 47670 Individuals and married couples arc 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 tar bills for all;therefore.
ill
HEA 1344-2009 requires tarpapers who receive the homestead standard deduction to verify that they are eligible to receive the
benefit and to preside additional identifying infomunwn necessary to allow county government to bolter monitor homestead
filings.This information will he kept confidential and can only be accessed by authorived county officials.The Department of
Local Government Finance will the this information to create tools that will help county officials eliminate homestead fraud.
PART 1: PROPERTY LXFORMATION
— Taxpayer Name Property Address
Chamberlain, Darryl/Jessica
109 W Mill
Patoka IN 47666
555
Darryl Chamberlain
109 W Mill State Parcel Number Lezal Description
PATOKA IN 47666
26-04-25-101-000.007-020 015-00007-00 PT NW 25-1-11 .52 AC
K
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PART 2:TAXPAYER INFORMATION
Owner I First Middle Last
R(ilL Lit t A Ike N C\aa_ln.lottAixt A/
-- ig Address(number and svect;city,sti3e,and ZIP code) --- — Same as
properly oddrev— — — - —- —- —
,0 , Q�.,f a14 /109 Wear "Li_ PA-To KA; IN Y7G& (o
Spouse First Middle Last
/ /I /
Jess /GA E/L, /✓ eA am er(a / n/
Mailing Address(Number and street,city-state,and ZIP code) ❑Same as property address
\--D o . "i3 o/ ark ./ 09 W . /0 , c-L. /,¢7ICA , ,N V7& (oto
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
unl Ily,he or she may be liable for back taxes and substantial financial penalties.
Ow ere
if 4 Date
PART 4:ADDITIONAL INFORMATION
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