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0 "'O CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD / SUPPLEMENTAL DEDUCTION
State Form 5473 (R1216-09)
�v Prescribed by the Department of Loral Govemmerd Finance
INSTRUCTIONS., See reverse side for 6firg instructions.
FORM YEAR
HC10
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CERTIFICATION STATEMENT
I (We) A X j iliA
certify that f�we) as my (our) principal
place of residence or am (are) buying the following described real property for which a Homestead Property Tax Standard Ded to hereby claimed
under contract On the date this application is filed, (date of fiing):
❑ I (We) own ❑ Am (are) buying under recorded contract
GIBSON COUNTY AUDITOR
❑ 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 ( a/ name)
Social Smxdy number of demant Drivers gcense I Identi&atixn I Other
Name of claimant's spouse (legal name)
Social Security number of claimant's spouse (last I" digds) Drivers license I Identification I Other number
Issuing State
of clahnam's spouse (last five digits)
CONTRACT ••r r
It buying on contract, Fee Simple owner's name
'
Recorders office where contract is recorded
Record number Page
PROPERTY DESCRIPTION
County
Township Taxing distn (city to
i )
Pycel�rMe r 1 �yy�. I
al �esc,�iP1iQ^
(J
Is the' pmperry m question:
of
Perty ❑ Annually assessed m°Ne home (IC 61.1 -7)
If any portion of the residential structure or the land not exceeding one (1) acre that immediately surrounds Ifiat structure is used te produce moome, describe the use and portion
of the property ubT¢ed to produce income.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES
County Township County
Township
1 hereby certify the above statements are true, correct and complete.
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r
Address elate aX LP
o , a
ASSESSOR USE ONLY TRUE TAX VALUE ASSESSED VALUE
HOMESTEAD NON-RESIDENTIA
ATI00%OFTTV
VALUE VALUE
Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
Other land
,-
(2)
NO�✓'
:x`iE't- Fc�.''z�:�-` -";
Total land (line 1 plus line 2)
(3)
Dwelling
(4)
,R'M f•� S"";x' -rxS
- T- .,_n.w_
Residential improvements or Annually
Garage
Assessed Mobile /Manufactured Home
(5)
Other Improvements
(6)
Total Improvements (fine 4 through line 6)
(7)
Total value (line 3 plus line 7)
(S)
1 here true, by certify the above is correct,
Signature of Assessor
Date signed (month, day, year)
and complete.
Verifying action - Signature of Auditor
Date signed (monfh, day, year)
STANDARD • r
20 _ pay 20 Lesser of 60% of the assessed value of the homestead or $45,000
Abrwiurslandbg any ofherpmvision, the sum of the deductions provided in IC 61.1 -12 to a mobrfe home that is
$ '
not assessed as real property or to a manufactured home Nat is not assessed as real property may net exceed
oneJatf (f thelu the mobile or manufactured home.
Signature o fa
Data Sig ned,((ppJn(Jp) day }y.{(
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