Homestead_Elpers (2)�,1I
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CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD / SUPPLEMENTAL DEDUCTION
S! .V State Form 5473 (R72 /609)
� � Prastribetl by Ne DepaNrent af Lacal Govertmeiri France
FORM YE�
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�NSrnucnoNS: see ,��.�a � �o� mr,g r�st,f,Ua„s. 0 4 2011
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I(We) Y� certify tha�Cl'(we) i Y(our) prindpai
place of residence buying the following described real prope for which a Homestead Property Tax Sfandard D�lic� fi�y daimed
under mnUad on date lhis application is filed, (dafe offi(ing): G�gSON COUN T
�(We) own ❑ Am (are) euying under recorded convaa
Am (are) entltled to occupy as a tenant-siockholCer of a cooperalive housing corporetion
� Have a beneficial interest in the ws[ or the right to occupy the property under the tertns of a qualified personal residence irust
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Name of tlaimant (legal name) -
Sadal d' (4st ) D' s fkense / Idnntinatian / Issu'vg 9a's
' af daiman� (lasf frve dgiGS) �
Nama of d' nt's s (lepal na
Sodal $enmry numbrl W WlmanCS spouse (WSt digtls OriveYS license I Identi(ralion /
. .-, .
II Giymg m oonUact Fee Simple owneYS name
Recordets afia: where conUed is recoNtd ' Remtl number Page
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��ty Tamship - T' d' 'd (city, Mwn, fo ip)
Parml mimba L.p9aFQesaiP� Is Ue poperty m 4uestion: �
r� Real pmperry ❑ AnnuaOy assessed rtrod'le home (IC 51.7-7)
If any poNOn o� Ne fesidentlal shucWre or Ne Wnd nol exceeding aie () aae thal4nmediatety su nds ihat strucWre u used to produce Irimme, desaihe Ne use and pwtion
of Ne pmperty uNtred to produce inmme. .
d�-�S-o�-�oo -a-�/. C��-�aJ
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Counry TownshiP Counry ' Townsttip
I hereby certify the above statements are We, corted and comptete. Src�nature imant �
MEress (num6er and strae; dry, slate, antl LPOOtle) �
w. o,L-� P� ce�son 7�L`v7�6S o�ensv: le ��.
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land not exceeding t(one) acre Immediatey �� ,�.. P`- 1 �9��
surtoundin residentialim rovements. (�) .`���Y,'...`b`�'�<.,.�x���=�?:�
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Other land � (2) � j�� � �
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Tofal land (lim 1 plus line 1) (3)
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ResltlenUal improvemenb orMnualty �Ilin9 ' (4) ' .�,.« i�s.Y: .-?s x d'?`a`�
AssessedMObik/ManufacWretlHome Gare e �;�`i'r���.y�^V3•S�}:.��i�
9 �5) fi'�P-F� 3 P�;�r.i=."�•'..�F'�.�5§',#.t,�e;„�
:FSS'``y �y '�X'.�%C
Other ImP�vemertts (C) �»_,.,,,,;j-�.�y7,:a�^�
7ota1 improvements (line I NrougA line � (7)
Total value (line 3 pl�s Ifne � (8) •
I hereby certify ihe above is We, cortect, Sgrawte oiASSessor Date signad (month, day, yee�
and complete.
Vaifyhg action - 59nawre af Puditw ' Date signed (rtmn(h, daY Y��
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20 _ pay 20 _ Lesser of 60% of the assessed value of the homestead or $45,W0
NWwitAslaMug eny other provision, Ihe wmW fhe deducliwis proHdM in IC Gf. f-12 to a rtmbde Irome Naf Is $
not essessed es ieel property w to a men�dartuied hortie Nef 'a rol assessed as ieel poperty may rrot axcsad
onBfiaH (fllJ d NB assessetl rdh/e a1 N9 rtn6de home wmanufarluied hwrie.
SignaWfa af Audltw Dale signed (rtanth. daY. Y��
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