Homestead_Goodman (2)"'° CLAIM FOR HOMESTEAD PROPERTY TAX
� ._ � STANDARD / SUPPLEMENTAL DEDUCTION
State Fortn 5473 (R72I6-09)
S � Prescn0etl by Ne Depa�ment of Lool Grnamment Fnanca
INSTRUCTiONS: See rarerse Side !or filirw instructions.
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MAR 0 1 2011
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I(V✓e) , certiC f88mryr�pjgpqafl q�arf�� prindpai
place of residence or am (are) ' g the following described real property fw which a Homestead Property Tax Standard Deduclion is hereby daimed
under conVacl m �he date Ihis appliption is filed, (date o7filing):
❑ I(We) own ❑ Am (are) buyirg under recorded contract
❑ Am (are) entitled to occupy as a tenant-stockholder of a cooperative housing corporation
� Have a benefidal interest in ihe Wst or the right to occupy Ihe pmperty under Ne tertns of a qualified personal residence Wst
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Name o mani ( / nema) .
' Srnuiry
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tt buyug om m�tract, Fea Simple arnrls `wne
Recordefs ofice where conUSG is recorEed ' � Recdd num6er Page
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�n�y Township T' disiria (rily, fown. townshiP)
ParrnJ numher I EesaiD� Is Ihe prJty in qu�ti '
SG.7 6-.3' // .: •/iG S� ❑ a�i aove�cr � MnuaOy assessM rtnWe home (IL 61.1-n
�' me ragdenua� smxwre or u,e w,e noc exrem�uq are (1) aae uiat muneaiatelr r,rra,�MS uiac so-uco,re is usee lo w��e Inmma. aesa,ta ttre use and poRion
W the ryoputy ubT¢ad to Wodum intort�e. �
oZ�o-lB- 0 6- 300 - o o y. 9 5�f -o a/ �
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Coumy Tovmship Caunry Tawrvship
I hereby certify the above stetements are We, correG and complete. 5 i
�dress(num6erands7e� aryslete,erNLPcode) .
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LanA not exceeding 1(o�re) acrc immediauy � �. �.��' ,'��`.�,��•".s`_t�'�:��
surtou�Mi resldentialim rovemen�. ( � �"..� s }'�`..�-s�K�
e;�tc�� �{.�
ONer land (2) :�-0sy..�;=•. . �F` .
7otal land (line 1 plus line � (3)
.u3�t'` s.l -�.r,:e��y^ '�
ResidentialimprovemenborMnualty �����9 (4) `� �Y'���s�'�'"��'��"�
Auessetl Mobile 1 ManutacWretl Home Garage (5) ��� ���` �Y.�C"��h ��`�`i:�:
.-ccsal
Other improvemenb (6) ,�''�.�`%<j�,,;`�z hy.�gx.
Total impmvements (llne I thmugh ltne 6) (7)
Total value (llne 3 pl�s line � (8)
I hereby certify ihe above is we, cortect, Sgrawre oi Asxssor Data signeE (month, day, }ea+)
and complete.
� Vaifymg action - Signature of Pudrtor Date 5i9�etl (rtanN. tlaY. Ye�
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20 pay 20 _ Lesser of 60% of the assessed value of Ihe homestead or $45,000 "
AblwitfutaMing enyWher pmvisbn, Ne sum o1 the deduclions pro�nded in IC &1.1-72 (o a rtrobl7e Mme Naf La $
rrot assessed as real poperry w la e menutactured hane Nat 'a not assessed es ieel properry may not esoeed
rnehaH(72f o1 Ne essesced relue o/Ne rtp6de home w manu/acNred home.
SSnaWfe W AuOttor - Date signed (monfh. daY. Y��
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