Homestead_Dewig (4) ' CLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR
4._.^- STANDARD I SUPPLEMENTAL DEDUCTION
.�@�y State Form 5473(R15/5-14) HC10
Prescribed by the Department of Local Goverment Finance
INSTRUCTIONS:See reverse side for fifing instructions.
NOTE:Telephone,Social Seamty,driver's license,state identification and federal identification numbers are con+•e rat I dx t IC 61.I -. .1_,
- _ . . .•_'• - ' CERTIFICATION STATEMENT""3' )t-s n r it' ' r; -
I(We) U I rS'_ _ certify that I(we)oc upied as my o�rincipal
place of residence or am(are)buying the ollowing described rea(roperty under contract for which a�qm,@stead Property Tax Standard
Deduction is hereby claimed on the date this application is signed, �BAW oiignata151(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 terytrgof a V idence trust.
❑ Am(are)the shareholder, partner, or member of the entity that owns the property. llii ll COUNTY AUDITO
` x -- T-'' t",:j.CLAIMANT'S iNFORMAliON?_ -: A
Name • ad it(legal name) Telephone number of claimant
V SIX e01Sq
Serial Seamy number of claimant(last five digds) Driver's License/Identifies=/Other number Issuing State
yte sera am(laNlnedga) 436tt
•
Name of claimant's use(legal name)
Social Semnly number of claimant's spouse(Iasi live dgas) Driver's license/Identification/Other number t Issuing State
of claimant s spouse(last five rigs)
R-t= : '' _ :. f it .a:'C:u CONTRACT,RECORDED.--:-3_T if?_�.Ja1c7.a` k.e_ .. :_• _i.
II awing on contact,Fee Simple owners name
Recorders office where mn•.raa is recorded Record number I Page
6s..- -eys. 3- '�-z•=.`-.PROPERTY DESCRIPTION:. ,�:e4 a�+_-zS`sxa., .r':_.=r.? :;
corny cs� Township K Taxing dis•.rict(nry.town,toenail')
Parcel num L17—� p r D(�O s v 4)v Val Lip Is the wrap rip quest-cm
- n:
❑Real property ❑PmuaT7 assessed mo6ie home(IC 6-1.1-7)
tf any potion of the residential structure or the land not exmEdag one(1)acre that immediately surrounds that structure is used to produce income.describe the use and portion
of the property ttiized to produce income.
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State._County,and Township Is claimant vacating a homestead?
❑ Yes ❑ No
Signature mart r
I hereby certify the above statements are true,correct,and complete. •
'��'�/��(�}��
Addles contact(mum^ aM s'eeL #ate,end ZIP I _rest of vacated hcnestead.2 any(number and 5rrb1!a.•y,Satp and ZIP cede)1
zwfool i i - c • St
ASSESSOR USE ONLY I ASSESSED VALUE I HOMESTEAD VALUE I NON-RESIDENTIAL
Land not exceeding one(1)acre immediately I(1)
surrounding residential improvements Ill
Other land 1(2)
Total land(line 1 plus line 2) 1(3)
Residential improvements or Dwelling (4)
Annually Assessed Mobile I
Manufactured Home Garage (5)
Other improvements (6) IL rppp(1•
Total improvements(line 4 through line 6) (7)
_
"i
Total value (line 3 plus line 7) (8) ��p
I hereby certify the above is true,correct, Signature of Assessor Date signed(montaYeear6 2015
and complete.
Ve:fyhg action-Signature of Auditor Date signed(mdnth. year)
e/
t} -x=, �:n7y -. .a _ya-s- STANDARD DEDUCTION ALLOWANCE,,— `q.-;:i :,r,. ,�-� 1./h.s�siif,^r„t AUDITOR
20 pay 20 Lesser of 60%of the assessed value of the homestead or$45,000
Notwithstanding any other provision,the sum of the deductions provided in IC 6-1.1-12 to a mobile home $
that is not assessed as real properly or to a manufactured home that is not assessed as real property may
not exceedo alt(12)of the assessed • kte of the mobile home or manufactured home.
Stowage of Date signed(=nab day,yearn
DISTRIBUTION: Orghal-County Auditor,Foe-Damped Copy-Taxpayer