Homestead_Johnson (8)�
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"'" CLAIM FOR HOMESTEAD PROPERTY TAX
, STANDARD / SUPPLEMENTAL DEDUCTION
� Y SUte Fortn 5473 (R72 / 6-09)
�O � P�escnbed by Ne Departmerrt M Loral GovemmeM Fnarce •
INSTRUCTIONS: See reverse side far �ding instnlcti0ns.
FI ��
APR 19 2011
YEAR
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1(We) ce ihrapt I` Iwa�d�iny (our) principal
lace of residence or am are ��75falrv �
p ( ) buying lhe followi described real property r wh' a Homestead ndard DeducUon is hereby daimed
under contraG on ihe date Nis applicatlon is fileq dete of filing):
�,�I (We) awn ❑ Am (are) buying under recorded contract
❑ Am (are) entitled to ocwpy as a tenant-stockholder of a cooperetive housing corporalion
� Have a beneficial interest in lhe Wst or the right to accupy the property under ihe terms of a quaiified personal residence Wst
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Name of tlaimant (legal nama)
Sodal Smnrty nmba d da'v�anl 69 fite ) DrivPJS Gcense / Identifitltion / Oiha Iiwu�g Saie
of tlaimanl (lasf Irva d'q'rts) �
Name ot da'cnanPs se (lepel nartre)
Sadal Seairiry rnimbnl ot daima 's spousa (las! five d'gGS) Dtivers Gcense / Idenfification / Olher
I� buying m contrad, Fee Simple ownefs �ume
RemrEe�s of6ce where mnUaa is remded Remrtl mimber Page
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���y Township r' dis ' �, rowr�, ro ip)
ParceJ number legal desaiption Is Ne property m qurslion: ,
' Real property ❑ AnnuaAy assessed moWe home (IC 61. i-7)
If any ponion oi ine resiCenlial swcNre a Ne IafW not exceeding ace (1) acre Nat MmeCiatey w ntls Ihat sWCture is used tn pWUCe irrowne, aescribe Ihe use and portion
ot the pmPeM uoT¢ed to W�uce incm�e. �
' � �-i � - zo - 3 cbc�y. 8�3 � - o a
-.. . .: . .
Caunry Township Caunry TovmsNp
I hereby certiy the above statemenis are we, cortea afM complete. Si cura o1 daimani n� �
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ress (number aM slraef, dry, state, and LPmOe)
` /�ao3 �..� �sos O�{ hs �;//c �N y76�s
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Land not exceeding t(one) acre immetliatey „`%�v��}+f.�'`a�..�t'���, �^�
surtoundin residential im rovementa. (» � =i4�"�.�a.:L`f���'.',.,s �t�f �_�
��:'s�.`-# }��-a i
Otherland (2) ;�.e_„ # ;�: -
Tofal land (line 1 plus line � (3)
rrrr �
Residentlal improvemenb or Mnuaily �Iling (4) �,.�,;�sts,�.,:*'� gT1�.�s�s�y3�?+�'�-�d�. �
Assessed Mobile / ManuFactured Home Gare a , -'�``�`3� `� - y7�+.z �-�ri`F�•-R�X �s.:
9 �5) � --w,.;j;if :'�'w..��s .:;9k�k�z
N:.:'-- '?vi. u."{.'i
Other improvemerrts (6) :�;�:?�.y�';ta'�t;
Tofal impmvemenfs (Ilne 0 Nrough line � (7)
roai �awe (Ilrre 3 plls line � (e)
I hereby eertiy the above is we, cortect, Sig"an"a °�AUess°` Date sg"etl p"°"m' d'y yea�
and complete.
VeiN��9 aGbn - Si9rature of PLCtw Date signcd (monN. daY. Y��
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20 _ pay 20 Lesser of 60% of Ne assessed value af the homesteatl or $45,OW
NohtiMS(arMhg any atherplovisun, fha sum o1 the dedutlions prowticW in IC 61./-12 to a mo6�7e frome �hat is g
na( essessetl es real poperty w to a manWactuied hortie Ne( a nof essessed as real poperty mey rot exmed
onehaN (f/� W Me assessetl rdlue d fha mobde frome or manularlured frortie.
Sig�at�ne of Nid"nor Date 5�y�eC (muaN. EaY. YEa�)