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` �� CREDIT/STA DARD D DUCT ON RTY TAX
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�� Sfate Fortn 5473 (R2 / S92)
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INSTRUCTIONS: See reverse side (or liling instructions.
FORM YEAR
HC10
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- CERTI CATION STATEMENT
I(We) iry that on the 1 s ay of March, 19_
I(We) occupied as our principal place of residence the foilowing described real property for which a Homest d Prope C t is her y c ed:
❑ I(We) owned ❑ Are buying under contract . GIBSON COUNTY AUDITOR
❑ Have a beneficial interest in the entiry that is liable for the property taxes on the property and that owns the property or is buying under a contract.
CONTRACTRECORDED
tl buying on conuact, Fee Simple ownefs name
Recorders oRCe where contract is recorded . Record number Page
PROPERTY DESCRIPTION
Counry Township Taxing district (ciry, town, township) I
Parcel number Legal descnpiion
- -d0 � •�t.�r -3-I � �
If any portion of e residen6al sWCture or Ne lantl noi exceeding one (1) acre that immediatety surrounds that sWCture is usetl to proauce income, tlescribe Ne use antl poNOn oi
the praperry utilized to produce inwme. �
c,��- %-/�- �-Qc�o. 3- ooz- .
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES .
County Towns�ip Counry Township
S na f daimant
iereby certify the above statements are true, correct and complete. o I
Addr (numberandstreetcity.s7are,ZlPcode)
�-1 o�c 2 �we� S � ��e � �766s
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE .
Land not ezceeding 1(one) acre immediately (�)
surtounding residential improvements.
Otherland (2) I
Total land (line 7 plus line 2) (3)
Dwelling (a)
Residential improvements
Garage (5)
Other improvements (6)
Total improvements (line 4 through line 6) (7)
Totat value (line 3 plus line 7) (8) (
I hereby Certiry the above is iNe, wveCt, and Signature of nssesor Date signed
complete.
Veritying acUon - Signature of Autlitor Date signetl
S7ANDARD DEDUCTION ALLOWANCE
19_ Pay 79 _
Lesser of 1/2 Homestead c�
Valuation or 52,000
Signature ol Audi:or Date si netl
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