Homestead_Bender (3)CLAIM FOR HOMESTEAD PROPERTY TAX -, FORM YEAR
CREDIT/STANDARD DEDUCTION Hcio
State Form 5179 (R6 / 4-031
Prescribed by the Department of Local Govemmem Fu
INSTRUCTIONS: See reverso side for hfinfl
I (we) - as Amillulel. om v- It, YW A J( t& - kx�- &JE41at"— - — certify that on the 1st day of March, 20
j�td
1 (We) 4our principal plaVif residence the following described real property for which a Homestead ProWRT4 (192(Ng5emby claimed:
❑ I (We) owned ❑ Are buying under contract
Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns the prop911"bi&tder a contract.
GIBSON COUNTY AULN [OR
NTRACT!RECORDEDi' --,
If buying on contract. Fee Simple owners name
Recorders office where contract is recorded Record number Page
F�ROPERTY15ESCRIPTION-IT�t-4����----:-d;.;"".'
County Township Taxing district (city, to", township)
Parcel number Le cnj . property in question:
0-0—S-1 lo- a4��p ❑ Real property ❑ Mobile HMO (I.C. 6.1.1-7)
H any portion cf the res,denbal stNaure or the land 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 income.
3JD
OCiOtfttY6W�tiiBYC"IMANt[NbTHER-1�difi4TIE�'-
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County
Township
County
Township
I hereby certify the above statements am true, correct and complete.
ign lure want
12 (;r ?t n)dfraat, city, sfafe, ZIP code)
7-
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aT
W&&66RUSEONLWV,�
�1 FA
,TRUEiTAX
ASSESSEDNALUE
' HOMESTEAD '�,4.!!,,,r.NON-
RESIDENTIAL:I.,r
-`VALUE
VALUE
Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
Other land
( 2)
� :
M
Total land (line I plus line 2)
(3)
Dwelling
(4)
Residential improvements or Annually
�. e-a
Assessed Mobile Manufactured Home
Garage
(5)
t
4
Other improvements
(6)
Total improvements (line 4 through fine 6)
(7)
Total value (fine 3 pits line 7)
(8)
I hereby certify the above is true, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
20 _ Pay 20_
Lesser of 112 Homestead $
valuation or 535.000 I
Signature of Auditor