Homestead_Schwartzlose (2)1
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CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD /SUPPLEMENTAL DEDUCTION
6 State Forth 5473 (R121609)
Prescribed by the Department of Local Govemmem Firmrxm
INSTRUCTIONS., See reverse side for fft instructions.
r• � rl 11��!�
JUN 3 0 2011
CERTIFICAT10N STATEMENT
I (We) certify lhuFyLva?1 pied as u principal
place of dence or a (are) buying the following descri real property for which a Homestead Property lax Sta�nldSaOOrd Dg M11T)4 fl#tQ�ned
d on the date this application is filed, (date of filing):
����u,,,,.....nder
(We) 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 terns of a qualified personal residence trust
INFORMATION
Name of d 'mart (legal name)
ZZZnsrbav
s ficense I Identification /
�?
Name of claimant's spouse (legal name)
Social Security number of claimant's spouse (last five digts)
Drivels license I Identification I Other number Issuing State
of dalmont's spouse (last five digits)
CONTRACTRECORDED
It burying an contract, Fm Simple owners name
Remmdels or" where contract is recorded Record number Page
PROPERTY DESCRIPTION
County
Township
Temdng district (city, town, township) ,
u mber
nu
Legal d p'
Is the property m question:
X O .. O _
•' �pQ �6 -�
❑ Real property ❑ Annually assessed motile home (IC 6-1.1 -7)
If any portion of the residential struchume or the [arid not exceeding one (1) acre that immediately surrounds that structure is used to produce income, describe the use and portion
of the property utilized to produce inmme.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES
County Township
County Township
I hereby certify the above statements am true, correct and complete.
Signature of der
t
'
Address (number and street, illy, state, and ZlPcode)
�0- � ct Q0 G
�-r� N o
ASSESSOR r r NON-RESIDENTIAL
AT 100% OF TTV VALUE VALUE
Land nor exceeding 1 (one) acre hn lately
()
surtoundin residential im rovements. -;-. -.::. •rr-- •sskr..:,,
Other land
(2)
W
Total land (line 1 plus line 2)
(3)
Dwelling
(4)
w Z x
Residential improvements ements or Annually
� 3
Garage
Ff � OTM_ V `t
Assessed Mobile 1 Manufactured Home
Other improvements
(6)
r_.
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(6)
I hereby certify the above is true, correct, -
Signature of Assessor
Date signed (Month, day, year)
and complete.
Verifying actin - Signature of Auditor
Date signed (month. day, year)
STANDARD • r
20 pay 20 Lesser of 60% of the assessed value of the homestead or 545,000
Notwithstanding any otherprovsion, the sum of the deductions provided in IC &1.1 -12 to a mobffe lame that is
$
not assessed as real property or to a rtanufactuied home that is not assessed as Mal property my not exceed
one -haff (1R) of the assessed value of the mobile home or manufactured home.
Signature of Auditor
Date signed (nanth, day, year)