Homestead_ScottA ° ;• CLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR
CREDITISTANDARD DEDUCTION I HCID
�' E1
Stale Form 5473 IR2 r 5921
Nil ,
INSTRUCTIONS: See reverse side for filing instructions. •�1
l(we) D—) Y -reea ,�1'>�C� �" iJ certify that o ry day of`M c 9
occupied as our principal place of residence the following desc' red real properly for which a Homestead Proper "ltl°yll�� nreteby claimed:
tWe) owned ❑ Are buying under contract JJ
❑ Have a beneficial interest in Ilse entity that is liable lot the property taxes on the property and that owns the propr -ti �,puyfA under a contract.
CONTRACT RECORDED
If buyiml on contract. Fee Simple owner's name
Reorrder's office where contract is recorded Record number Page
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES
courtly
PROPERTY DESCRIPTION
county
Township
by ce tily the above statements are true. correct and complete.
Taxin1`g disl1ri I I town. to Ship)
P arcelnumber
o�v ooZ
Legal desc ron
� e5 -
- - �a�e -721-9- aid
It any portion of the residential structure or the
land not exceeding one (t)
aue that immediately surrounds that structure is used to produce income. describe the use and portion
of the properly utilized to produce income.
Total land (line I plus line 2)
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES
courtly
Township
Counly
Torrnshrp
by ce tily the above statements are true. correct and complete.
nal a olefaimant
Address (number and street. oily, state. ZIP code)
ASSESSOR USE ONLY
TRUE TAX
VALUE
ASSESSED
VALUE
HOMESTEAD
VALUE
NON- RESIDENTIAL
VALUE
Land not exceeding I (one) acre immediately
surrounding residential improvemenls.
(t)
Valuation or $2.000
Signature of Auditor Date signed
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 61
(7)
Total value pine 3 jobs line
I hereby certify the above is true. correct. and
complete.
Signature of Assessor
Date signed
Verilying action Signature of Auditor
Date signed
O
STANDARD DEDUCTION ALLOWANCE
19 __Pay 19
Lesser of T12 Homestead
$
Valuation or $2.000
Signature of Auditor Date signed
STATE FORM 53569(R3/3-10) TREASURER FORM TS-IA
APPROVEDBY:SATE BOARD OF ACCOUNTS,2009 PRESCRIBED BY THE DEPARTMENT OF LOCAL GOVERNMENT FINANCE IC6-I.I-22-3.1
- . : 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
uses higher tax bills for all; therefore, HEA 1344-2009 requires taxpayers who receive the homestead
s dard deduction to verify that they are eligible to receive the benefit and to provide additional identifying
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.
--- PARTI: PROPER 'V INFORMATION - :"
Taxpayer Name Property'Address State Parcel Number Leal Description:
David A/Kelly D Scott 178 w 400 N 26-05-48-099-000.769-018 PT LOC 99 I-10 6.5 AC
PATOKA IN 47666 C-1
Complete and return to: I lIgINME�@ Ip II11�m��m7 EMU
GIBSON COUNTY AUDITOR, 101 N MAIN PRINCETON IN 47670 ill IJ J aY
- PART 2:TAXPAYER INFORMATION `
Owner 1 ( n�\ First Middle `n (��\ fast
Mailing Address(nlmber and sheet,city,state and ZIP code)
1 —1 LA vV r ) Same as property address
LL)
4 First Middle \,.r1 Last
�v I lU y `\ ,c.„-ti---
Mafmg Address(number sheet,city,state and ZIP code) �` Same as property address
m LO Lk.CSO `rm
. -
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.
Canner 1 Signature Date
PART 4: ADDITIONAL INFORMATION
FILED
, ,
• DEC 14 2012
CAD //
uttsSOI COUNTY AUDITor' _