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Homestead_BirkCLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT /STANDARD DEDUCTION
State Form 5473 (R51 10-01)
Prescribed by the Department of Local Government Finance
INSTRUCTIONS: See reverse side for riling instructions.
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FORM V� YEAR I
I d*D1
1 (we) Is.4 - A&8IC4 3r- t�_ - �Xtj4e44�Lhat On* s()[1y TOV, 20
1 (We) occupied as our principal place cr[I;&O� e the fioll;,A3de I
"c y fo�whtch a Homestead Property Tax Credit is hereby claimed:
❑ 1 (We) owned ❑ Are buy' 7un-dee, contract
1W ct.ave a beneficial interest in the entity that is liable for the property taxes on the property and that owns t r C
N djo t, igt&nd6r'6U
hfl� BS N 01-N-1 , AUDITOR I
,-,'yb,lP-����-tONTRACT'RECORDED-4��--
If buying on contract, Fee Simple owner's name
Recorders of where contract is recorded Record number Page
OR60-ERTY, DESC RfRTION I3W:s r4jr
County
Township
Township
Taxing district (city, town, township)
pan r
cription
enq be street, ale, ZIPc e f4�) 1,4
Is the property in question:
5f:
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1 ❑ Real property ❑ Mobile Homo (I.C. 6-1.1-7)
If any portion of the residential structure or the land not exceeding we (1) acre that immediately surrounds that structure is used 0 produce income, describe the use and portion
of the prop" utilized to produce income.
surrounding residential Improvements.
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PROKEk1*6WNE6B? CLklMA-WT.fN6TFiEk'"&(5LfkTIES�I
-TRUE TAX'
aj
County
Township
I County Township
I hereby certify the above statements are true, correct and complete.
igna ure of claimant
enq be street, ale, ZIPc e f4�) 1,4
I - - - - I I - * - — I — —
3 ul
AMM& S1' NLN�-
-TRUE TAX'
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ASSESSED -.VALUE
_!HOMESTEAD�9.
-RESIDENTIA
�NON�
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;j.Z�ftf
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Land not exceeding 1 (one) acre immediately
surrounding residential Improvements.
Other land
(2)
Total land (fine I plus line 2)
(3)
Dwelling
(4)
Residential improvements
t;t Z.�
Garage
(5)
ge
Other improvements
(6)
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(8)
1 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 $6.000
Signature of Auditor
S
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