Homestead_Johnson (6)CLAIM FOR HOMESTEAD PROPERTY TAX Fo� YEpR
_ � STANDARD / SUPPLEMENTAL DEDUCTION HC10
! � SFate Farm 5473 (R73 / 12-09)
� � Presaibed by the Department of Laca� Gwemment Finaxe
uw
INSTRUCTIONS: See reverse slde for filirg ins6ucmw�s.
I(We) certiry that I(we) occu�� �s�� (our) prindpal
place of re ence am (are) buyi ihe following described real property tor which a Homestead Property Tax Stan�� o�i ereby daimed
er con cl on ihe date ihis application is filed, (date ol filirg). 1(We): �.�
C.'J.�� �' V
Own ❑ Am (are) buying under recorded contrect
❑ Am (are) entllled to occupy as a tenant-stockholder of a moperative housing corporaGon �i(; p�NTY AUDITOR
❑ Have e benefidal mterest in Ne Wst or ihe rigM to ocwpy the properiy under �he tertns of a qualified per��5idence Wst .
❑ Am (are) the shareholder, pariner or member ot the entlty that owns Ihe property.
�
(legal name)
(k�a� reme)
spou.m (las five dgks)
If bynng on conLacC Fee Simple owners rame
�vhere contract is recartlee
Counry
Pafcel number
Orivers ficertte 1 Itlentlfiption!
of daimant (last frve digits) � � � �
of da4nanCS spouse (last five dgds)
�
y . . i l .t-1 'l �:� f
D.u�".� _.:�ts rlix.�J:'i`�°R"r4 !:a Rf sf.s.: __, nCz'-'i.i,.
- �
ION"� `'`yi�5.e. F--k. '�':1.��.x`ti�?-?'G �T�t't;:�i�a. e��
1�U1�
�.�_�. _
I�� �pf L, ��'.CH L+[1�7 I.i� �1 popgty U AnnuaDy assessed rtwb0e larne (IG 67.1-7)
If arty poRion ol Me 2sidential struclure or Ne land iwl exreedi� ane (1) acre Nat immediately svrtountls ihat sW ch�2's used W produce ir�come, tlesrnbe the use and poNOn
of the property utifaed to protluce Income.
�l�-��-0 1-30�-0� 3. �5 7- oa 1
Tamship
counry
I hereby certiy ihe above sfatements are We, correct and complete. I:
Address (num0er end streel, ary, stefe, aM LPCOda)
K 51(� 5 5�]oo w [� w��sv; lle =�.1 �4�7
Land not exceeding t(orre) aere Immedlauy
surtountling resldenUal Improvements.
Other Wnd
Total land (line 1 pluslure �
ResidenUal Improven
A.sessed Mobtle I Ma
Other Improvemenb
Dvrelling
or Annually
3ured Home Garage
7ota1 improveme� (line I
Total value (line 3 plta Illre �
I hereby eertlfy the above is We, correet,
and wmplete.
Veifying allon - Sigreture of fwtlitnr
(�)
�2)
(4)
(5)
(6)
�8)
SignaWre of Assessw
20 _ pay 20 Lesser of 60% of the assessed value ot Ne homestead or $45,000
Nolxiths(endyg anYWherprovision. (Aa sum oI Ne ded�ctbns povided in IC 8-/.7-72 ro e rraW7e fama fhaf is
not essessad es rael pmperty w to e menufacfurad home Nal is nof esmssed as real property may not exceetl
.,,,..i,<n ��n� nrrn1. aeew.cua vwnre or ure mobtie home ormanufechired honre.
$
Township
Date signed (monfh, dey,
Date signetl (mon�h, daY• Y��)
Signaeue of Auditor I Dete signed (mon(h, day, yea�