Homestead_Johnson (18) r j
STATE STATE BOAR TREASURER IC FOPM
t.1iS1A
APPROVED BY Sr.�TEBWRD(F ACCOUNTS,1009 PREiCRI9maYlHE 6PMiA41.TCF lACli1.GOVFNI�Yi FINANCE le41.1-ll1t
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
icounty officials eliminate homestead fraud.
PART 1: PROPERTY INFORMATION
Property Address(number and street,city,star ZIP c e)
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State Parcel Number
. IL��
1 FEB c
?0/5
PART 2:TAXPAYER INFORMATION
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Owner I First Middle : CO / Last
jer Loo��i
Air
G94XJ ryAVOITpp
g Address(number and street,city,state,and ZIP code) "" Same as property address
I
Spouse . Middle Last
1 .
Mailing Address(Number and street,city,state,and ZIP code) 0 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)
Stale
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.
Owne I ignatur
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PART 4:ADDITIONAL INFORMATION
I
1
I INSTRUCTIONS
CLAIM FOR HOMESTEAD PROPERTY TAX FORM I J YEAR _
CREDIT /STANDARD DEDUCTION cta
State Form 5473 (RS 14-03) M
Prescribed by the Department of Local Government Finance Lj
INSTRUCTIONS: see reverse side for riling instructions.
E_RTIF.ICATION STATEMENT -. ii'+i;,: -+�'.. v'iLiyn,+�it•..'.. , - . 2
11�\ v,
I (We) I1 Arm-? . \k i _9.JZn, „ `a• 4N n r\� �„A certify that on h Ast day of'March, 20
ppI..�(We) occ ed as our principal p a f residence the follow described real property for which a Homestead PC; 'ttCJNaYCJuT
WUIi�.he[ebydai(ned:
I (We) owned ❑ Are buying under contract
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 under a contract.
5 '"'.' .• s -a 'z a a 7
�s.�'- rir'','evi•f.'..i. :CONTRACT. ?RECORDED ;•'>LirXa rn'•d tStvT?,� -Y �+r ^r-- C.s.''. 0%;?'S`'
If buying on contract, Fee Simple owner's name
Recorder's office where contract is recorded Record number Page
RTY DESCRIPTION ' r -
County
Township
Taaing district (city, town, township)
Parcel number //
1 -
Legal description
Is the property in question:
I property ❑ Mobile Home (I.C. 61.1 -7)
If any portion of the residential structure or the land not exceeding one (1) acre that immediately surrounds that swcture is used b preduce income, describe the use and portion
Of the property utilized to produce income.
C700 -Co/. /7o -COX/
k- z- F �"Fi Ar'• [T 3.r'. 3r' - ... _ _ _.._
.:�.t'...:t?ROP.ERT.Y,OWNEDBY CL'AIMAN7.INOTHER' COUNTIES? �}`.'>.� „,�`+„I';�.- ,Z"?n"r. *,,
County Township
County Township
1 hereby certify the above statements are true, correct and complete.
§ignaturq of claimant
'dress (number and street, city, state, ZIP code)
10417 GI Ra
VAL_UJ',_
- TXCi34r.`�`
;;,'ASSESSOR USE ONLY?`��
}-'d�ancC..F-'Ysh
.y ]{ 4
6 TRUE TAX :
T+
ASSESSED VALUE
.il
kHOMESTEA�
';
vYC'
NON= RESIDENTIALu
�a�r
'
VAL_UJ',_
AT 700% ,OF --, N2l
'.6tXAVALUE.a�.
Q'I"UE'��`.�
Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
Other land
2
()
Trial land (line 1 plus line 2)
(3)
Dwelling
(4)�
Kati '`F F� >Y
s' 4
Residential improvements or Annually
,
Assessed Mobile /Manufactured Home
Garage
a
(5)
Other improvements
(6)
£ '.-
Taal improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(6)
hereby certify the above is true, correct, and
Signature of Assessor
Date signed
complele-
Verifying action - Signature of Auditor
Date signed
STANDARD' DEDUCTIONALLOWANCE91 -e*
20_Pay 20_
Lesser of 112 Homestead
valuation or 835.000
$
Signature of Auditor Date signed