Homestead_Conklinr �
CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD /SUPPLEMENTAL DEDUCTION
x State Form 5473 (R1216.09)
Prescribed by the Department of Local Government I manca
INSTRUCTIONS: See reverse side for filing instructions.
AUG 3 1 all
v
i r
�---------- u- -- ---- -- - -- -a-
�J
I t I (VJe) t Toccupl s my (our) principal
place of residence or am (are) buying the following described real p erty for which a Homestead Propgr�ff(v5td)Dediq�)gn�(Qreby claimed
under contract on the date this application is filed, (date of filing):
❑ I (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 terms of a qualified personal residence trust
INFORMATION
Name of ( name)
Sodal of m (6stfire ig3s)
Drivers license / I Other
Name
Social Security number of innt''s spouse (last five digds) Ddvees licei / Idwd'mdm / Omer number Issuing State
of claimant's spouse (last five digits)
((( /K
• • • r •
If buying on contract, Fee Simple owners name
Recorders office where contract is recorded
Record number Page
PROPERTY DESCRIPTION
n
Township Taxing district (city, to
arcel number al description - Is property in lion:
0093 - O p� l LLJ Real property ❑ AnnuaP/ assessed mobile hone (IC 6.1.1 -7)
If any portion of the residential suuchme or the lard not exreedug one (i face mat immediately surrounds that structure Is used to produce income. describe the use and potion
of the pmperty utilized to produce income.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES
County Township County. Township
I hereby certify the above statements are true, correct and complete.
Si of claimant -
1
Add�ss (number sheet. rift'. state, an�d�L)P code)
O �� //5
ASSESSOR • r • r NON-RESIDENTIAL
Land not exceeding 1 (one) acre Immediately 1
surrounding residential improvements.
Other land
(2)
y^
Total land (line 1 plus line 2)
(3)
Dwelling
(4)
Residential Improvements or Annually
Garage
Assessed Mobile / Manufactured Home
(5)
Other improvements
(6)
". r;:fti y`+ N
Total Improvements (line 4 through line 6)
(7)
Total value (fine 3 plus line 7)
(8)
hereby certify the above is true, correct,
Signature of Assessor
Data signed (month, day, year)
and complete.
Vert" action - Signaw. of Aadtor
Date signed (month, day, year)
STANDARD DEDUCTION ALLOWANCE
20 pay 20 Lesser of 60% of the assessed value of the homestead or $45,000
rlotwitlsmrddg any olherprovision, the sum of the deductions provided /n IC 6.1:1 -12 to a mobft home that is
$
not assessed as real property or to a ma dactured hone that is not assessed as real property my not exceed
oneJaH ) tithe assessed value of clue qobde tame mmamdacured home.
or
Date �ggep'�rxx /hie qe�
�---------- u- -- ---- -- - -- -a-