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CLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR _
s; CREDIT /STANDARD DEDUCTION HC10
State Form 5473 (R2 / 5 -92)
Vu
INSTRUCTIONS: See reverse side for filing instructions.
CERTIFICATION STATEMENT. - 1
I (We) _ Ei� "%t i I 7� r S -�"L�� certify t on a st(tl -df rch, 19
-'9) occupied as our principal place of residence the following described real property for which a Homestead Pr ert - i-, Cre4dit��gteby claimed:
(We) owned ❑. Are buying under contract - f A 2 `I U
❑ Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns the property or is buyinggpder a antrVt.
✓)'`J in LI4t)II-
CONTRACT RECORDED
It buying on contract. Fee Simple owner's name
Recorder's office where contract is recorded Record number Page
` - PROPERTY DESCRIPTION
_
Court
Towns .p / o
Taxing district (-
to , t'owrivio)
SRv
r Address (number and street, city. state. ZIP code)
Dade
Li a//
"
parcel number Q I Q Q O DL-J&
Legal description
/
Total land (line I plus line 2))
It any portion of the residential structure or the land not exceedin rte (1) ac hat immediately surrounds that structure is used top uce rcome, scribe the use and portion
of the property utilized to produce income.
Ell
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES '
County
Township
County
Township
�eby certify the above statements are true correcland complete.
Signature of claimant
r Address (number and street, city. state. ZIP code)
Dade
Li a//
- ASSESSOR USE ONLY -
-
TRUE TAX
..VALUE
ASSESSED
VALUE.
HOMESTEAD
VALUE
NON - RESIDENTIAL.
VALUE
Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
(1)
Signature of Audit
Dade
Li a//
"
Other land
(2)
Total land (line I plus line 2))
(3)
Residential improvements
Dwelling
(4)
Garage
(5)
-
Other improvements
(6)
Total improvements (line 4 through line 6)
(7)
Total value (line 3 pUs line �)
(g)
1 hereby certify the above is true, correct, and
complete.
Signature of Assessor
Date signed
–Verity ing action - Signature of Auditor
Date signed
- STANDARD DEDUCTION ALLOWANCE -
19 _Pay 19_
.
Lesser of 1/2 Homestead
luation or $2,000
5
—signed,
Signature of Audit
Dade
Li a//
STATE FUEM S 569(R_/789) TREASURER FORM TSIA
APPROVED BT STATE BOARD OF ACCOUNTS.M5 PRESCRIBED BY PIE DEPARTMENT OF LOCAL GOVERNMENT FINANCE IC SI.I::'51
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
county officials eliminate homestead fraud.
AIL
PART 1: PROPERTY INFORMATION
Property Address(number and street,city,state,and ZIP code)
II9a N 01C (AS T y / OCT2. 2013
State Parcel Number I
al,, -o4-a(0- aoa-000 sa (-oap ( IRSON coutmr AUDITOR
� �- 1120- 91oi5—cd
•
•
•
PART 2:TAXPAYER INFORMATION
Owner I First Middle Last
h n W l I K l s orb
Mailing Address`(number and street,city,state,and ZIP code) Same as property address
Spouse First Middle Last
Cat I•, n W I I k t S O
Mailing Address
/n(Number and street,city,state,and ZIP code) Same as property address
CS „`
/
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.
Ownener�Signature Date
INSTRUCTIONS
M °Z EX