Homestead_Booker CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
4_ Y STANDARD!SUPPLEMENTAL DEDUCTION FORM
' State FOrrll5473(R16/S1<) HCI0
• Prescribed by the!Department of Local Government Finance
INSTRUCTIONS:See reverse side for filing instructions.
n
NOTE:Telephone,Social Security,driver's license,slate idenbf action and federal identifcalion numbers are confidential unit. I 6-l 1-1 37. I 1 I
.�/CERTIFICATION STATEMENT r;?'_„ - - - -.
I(We) �/� l� — .iftzflS`A•4tie certify that I(we)occupie y4y()Pjy @al
place of residence or am(are)buying the following described real property under contract for which a Homestead of ia'h 5ddrd
Deduction is hereby claimed on the date this application is signed, (date of signature). I(We):
XOwn. ❑ Am(are)buying under recorded contract. , I -ti
❑ Am (are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation. (�11pp��//TT�A1I /I��T��1YU5T�y �a
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a qu2liTetl'pMSbrttn` lsibr ce AUPITOR
❑ Am (are)the shareholder, partner, or member of the entity that owns the property.
_
If tsry'ug on contract.Fee Shupe comets name
Recorders obm where conttract is receded 1 Record number Page
v_ _- - .a-- -:v.na•.-1
!_� y�,-�-._„�,-�ve_y „ _ _S PROPERTY DESCRIPT'Jh y,._-i- .z. » c.'�'. pea_-i,a�=-•>=ivi
coon C� —' rowmmp- Ta'elg �'r
Para number I Legal desoiptim Is the property in quesaonc
Oro,/a/6-xao-moil a/-oa 7 Real property ❑Anmuaay assessed mobile home(IC f-t 1-7)
If arty portion of the residenttial sate or the land not esceedhg one(I)acre that wnedatehy sunau s that suucure s used to produce hanme,desende the use and porr on
of he propeM uif ed to produce homme.
PROPERTY OWNED ELSEWHERE BY CLAIMANT
Sx)te CCouuntyy,,,yand ToowwnshipC Q / �^.�r� (((��� Is ant vacati g a homestead?
'SPIN/ (/j'(? 1 I' • •..JIB & LI Rc ccsL\onl4 n Yes ❑ No
I O C.. Spnature of damam
I hereby certify the above statements are true,correct,and complete.
Address of conact(number and street my,Sate,and ZIP rode) Address of vacated homesead,d any(number and-•:; a%sta'e,a ZIP nude)
&that°. 1c ..11 I i_ �∎._� (' . . ./� .5./�V”;( a 6 1 ,
ASSESSOR USE ONLY I ASSESSED VALUE HOMESTEAD VALUE I NON-RESIDENTIAL
VALUE
Land not exceeding one(1)acre immediately I(1)
surrounding residential Improvements 1
Other land (2) /wy�
Total land(line 1 plus line 2) (3) I I _
Residential improvements or Dwelling (4) I $6
Annually Assessed Mobile I - I 4 / I 1 \S Manufactured Home Garage (5)
Other improvements (6)
Total improvements(line 4 through line 6) (7) I 1
Total value (line 3 plus line 7) (8) I I
I hereby certify the above is true,correct. Signature ct Assessor
and complete.
Vadyhg ad n-Sgnature of Aud:a
63(ft . e-455 _ t,>. a.4.--- -• -:,-1LSTANDARD DEDUCTIONALLOWANCE -•ire-_ - .- „...„..� a.
20 pay 20 Lesser of 60%of the assessed value of the homestead or$45,000
Attaithstanding any other provision,the sum of the deductions provided in IC 6-1.1-12 to a mobile home S
that is rot asse' ••as real property or to a •uractured hone that is not assessed as real property may
not exceed• -h. (12)of the assessed of the noble hone or manufactured lame.
Sgna'ue d.,•.o T Date sgned(north,d/,year)
4 3-a i S'
DISTRIBIRION: Onginal-County s-car,Fie-Stamped Copy-Taxpayer