Homestead_ChamberlainYEAR
CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT /STANDARD DEDUCTION
State Form 5473 (R5110 -01)
Prescribed by the Department of Local Government Finance
Iti
INSTRUCTIONS: See reverse side for filing instructions. F
log 'CERTIFICATION STATEMENT�. -
I (we) L-t-- Y 4 / I 1C,11L.,-4 k--� A�� &Z!X�4� certify that on the I st day of March. 20
1 (We) occupied as our principal place of residence t lowing described real property for which a Homeste%adoperly Tax Giediahereby/claim f 'd.
tf/ Tax C" e
❑ l(We)owned ❑ Are buying under contract
GIBSON COUN
qoiave a beneficial interest in the entity that is liable for the property taxes on the property and that owns the property or is buying under a contract.
CONTRACT!RECORDED�a-,'---' ,sr -� '
If buying on contract. Fee Simple owners name
Recorder's office where contract is recorded Record number Page 77
`PROP ERTYD -ESCRIRTIONar
County
TamShip
C r, 'If
Taxing district (ci4 hip)
Aci MA-rd
Township
Parcel number
Legal dftzv 0 Is the property in stion:
7'
AT 100% OFTTy
M,� —Wl-inb
. — property' Mobile Homo
V
. 61.1.7)
If any portion of the residential structure or the land nor 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.
o,? -
Tx 9,ma`V-A- . ,PROPERTY DINNED BY CLAIMA,
WTRUE TAX `,
County
I Township I County
Township
I hereby certify the above statements are true, correct and complete. Signau" of claimant
I Cz -N z PA
street, city. star
W-I S VPr of L6 k�6n77 code) 3 - 10!,L,0t7,4-L1)'J12,z Tk 471,6,5
'1- k;?4 -1'STANDARb:DEDUCTION'ALLOWANCEtt�—
WTRUE TAX `,
ASSESSED VALUE
-HOMESTEAD
, NON.RESIDENTIALN R .%
rs, j�
VALUE; j._
AT 100% OFTTy
Lesser of 112 Homestead
WAL IWO
Land not exceeding I (one) acre immediately
S
r. T y
surrounding residential improvements.
Sign MeofAuditoW,ff,",
( aoq
11
U
Other land
Da n
(2)
i Total land (line I plus line 2)
(3)
Dwelling
(4)
r 'r,
Residential improvements
Garage
(5)
Other improvements
(6)
%W, e-
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
'1- k;?4 -1'STANDARb:DEDUCTION'ALLOWANCEtt�—
20 Pay 20
Lesser of 112 Homestead
S
Valuation or $6,000
Sign MeofAuditoW,ff,",
( aoq
11
U
Da n