Homestead_Michel (12) CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
, STANDARD/SUPPLEMENTAL DEDUCTION FORM
State Fran 5473(R15/5-14) HC10
Prescribed by the Department of Local Goverment Fiance
INSTRUCTIONS:See reverse side for filing instmcftons
NOTE:Telephone,Social Security,driver's license,state identification and federal identification numbers are confidential under IC 61.1-12-37.
CERTIFICA710N STATEMENT'. _ _''+-.,.
I(We) S t LL o rrt v- k r i 5 5 I e certify that I(we)occupied as my(our)principal
place of residence or am(are)buying the following described real property under contract for which a Homes 3����TTTTax r.
Deduction is hereby claimed on the date this application is signed, (date na reel l(We ID'
CI Own. ❑ Am(are)buying under recorded contract.
❑ 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 persFellence)V1Rk
❑ Am(are)the shareholder, partner, or member of the entity that owns the property. ���U��JJ
If buying on condact.Fee Simple ovners name
r Recorders o.tce where contract is recorded Record number 1 Page
%::L-- _1.2-11.-•-L. ;._ - '.-3'41•4' :2 1-.e PROPERTY.DESCRIPTION`».a_ ..0 n_.' .a-. '_ • . ....?t
Ccomy Township Taxing° '°(any,Rau,townsh%o)
nI0n.
Parcel number Legal description Is:le property in question:
Real property ❑Annually assessed mabie home(/C 61.1-7)
It any portion of the residential sauaore or the land not exceeding one(1)acre that immediately surrounds that structure a used to produce income,describe the use and portion
of the...rpe,.y utff ed to produce cowrie.
10 — IS I ` A - 300 — coo ,1kS 0x5
PROPERTY OWNED ELSEWHERE BY CLAIMANT
Sue,County.and Towmkp Is claimant vacating a homestead?
❑ Yes ❑ No
Signa:u.. . • imam
I hereby certify the above statements are true,correct,and complete. )( /
Address of contact(number and srree4 state,and DP ode) L 1 Address of va - .•hmostea•,if-.y(number and Sriet c y, ,,tea VD rode)
Land not exceeding one(1)acre immediately I(1)
surrounding residential improvement
Other land I(2)
Total land(line I plus line 2) 1(3) I
Residential Improvements or Dwelling (4)
Annually Assessed Mobile/
Manufactured Home Garage (5)
Other improvements (6)
Total improvements(line 4 through line 6) (7)
Total value (line 3 pits line 7) (8)
I hereby certify the above Is true,correct, Signature of Assessor Date signed(month.day,year)
and complete.
Yarning amen-Signature of NOar Date signed(month,day.year)
" -t-5 c4_.- 'e t a ?-- 'STANDARDDEDUC11ON ALLOWANCE74?;- Ate ra.=v y _ '=:�
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 6-1.1-12 to a mobile home 5
that is not assessed as real property or toe manufactured home that is not assessed as real property may
not exceed one-half(1R)of the assessed value of the mobile home or manufactured home.
Signet:. // • ` Date signed pnpmh,day.year)
T SLr2-1_, �J772/{ 07 — 49— i. 7
DISTRIeul10N: Ongial-Carty Asada Fee-Samped Copy-Taxpayer