Homestead_EllisCLAIM FOR HOMESTEAD PROPERTY TAX FORM
CREDIT/STANDARD DEDUCTION HC10
State Form 5473 (R614-03)
Prescribed by the Department of Local Government Finance
INSTRUCTIONS: See reverse side for filinq instructions,
I (We) A MJCf ( K-XX-U certify that on the I st day oi-Aarch, 20
I (We) occupied as our principal place of residence the following described real property for which a Homestead Property Tax Credit is hereby claimed:
1 (We) owned El Are buying under contract L - '�/ /
GISS01,; d0j\ �' -UL) '6�
for the property taxes on the property and that owns the property or is buyin'g u�dera contract.
Have a beneficial interest in the entity that is liable
ONTRACT.:RECORDED
If buying on contract, Fee Simple owmer's name
Reoordees office where contract is rewrdod ��mmnbe, Page
"-STAN6ARE).DEDUCTION"ALILOWANCE
20—Pay2O_
Lesser of 11:2 Homestead
value S35.000 F
Oro,
Date signed
ROPE RT,-Y -6E S C RWT11314
County
I hereby certify the above statements am true. correct and complete.
Twmship
Address(n bar and street, city state, ZIP code)
Taxing cfiM��
W"
W
Permit
Leg a
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—1 W
I th m uestion:
16-op R it property El Mobile Home (I.C. 6-1.1-7)
If my lon of the residential structure or the land not exc4-ding
of the property utilized CrZ307 7-OD
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one (1) acre that immediatety surrounds that structure Is used to produce Income. describe the use and portion
"-STAN6ARE).DEDUCTION"ALILOWANCE
20—Pay2O_
Lesser of 11:2 Homestead
value S35.000 F
Oro,
Date signed
County Toomship
County nship
I hereby certify the above statements am true. correct and complete.
ign ure of c I I
Address(n bar and street, city state, ZIP code)
- R / &S,/ 1410 0-1-e /-D.,i IAI
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ASSESSEDYALUE
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Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
Otherland
(2)
A
Toal land (fine I plus line 2)
(3)
Dwelling
(4)
MEN '151k
Residential Improvements or Annually
Assessed Mobile I Manufactured Home
Garag�
(5)
Inal -
'
f4 czi
Other improvements
(6)
*-
ME-- NISSAN
Total improvements (line 4 through line 6)
(7)
Total value (fine 3 plus Me 7)
(8)
I hereby cerfify the above is true, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
"-STAN6ARE).DEDUCTION"ALILOWANCE
20—Pay2O_
Lesser of 11:2 Homestead
value S35.000 F
Oro,
Date signed
•
snit rotN!,sn ot: .., r4FA5I:LFA!OtM11A
.AITROVEn BY STATE&iRD M AMOUNT t MY PLEXAfnWD BY nit bEPAATMEYT OF LOCAL 00VIRNMCNT FINANCEEWVI.I^J.1
Gibson County Auditor
101 N Main IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS
PRINCETON IN 47670 Individuals and married couples arc limited to ore homestead standard deduction.As the receipt of this deduction becomes
more beneficial,there is more incentive than ever for homestead fraud.Ilomeste:ul fraud causes higher tar bills for all;therefore.
HEA 1344-2009 requires taxpayers who receive the homestead standard deduction to verify that they are eligible to recene the
benefit and to provide additional identifying information neees ry to allow county goverment to better monitor homestead
filings.This information will he kept confidential and can only be accessed by authorized county officials.The De annienl of
Local Government Finance will uxe this information to create tools that will help county officials eliminate homestead fraud.
PART 1: PROPERTY INFORMATION
Taxpayer Name Property Address
Ellis, Chad A/Katie L
ItI
Hazleton IN 47640
209
Chad A Ellis
1318 E 870 N _ _- - - - __ — - - -State-Parcel-Number--- - - - tegal.Description- -
- -
Hazleton IN 47640-9248
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PART 2: TAXPAYER INFORMATION
Owner I t • First Middle Last
(, h Midd
ad- A Eilis
•nc Address(number imd street,city,state,and ZIP code) - ' Same as property addr s — --
J jig E 8 -70 N )-Icz z Imo" I N 471040
Spouse First Middle _ Last
Kee, L- L// i
Mailing Address(Number and street,city,stale,and ZIP code) ® Same as property address
13-) g 276- nJ - -)-{a 2/41 - - - - -
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.
Owner I Signature Date
•
