Homestead_Johnson (9)�.
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O'�M,^• � S�DARD / SUPPLEMENTAL DE UCT N��a {� FoR YE�
StateFOrtn5473(R72/6-09) �q[� �� EHC (�
�O 2 Prescn6ed by Ne Depanment of Laral Gwemment Fi�anca / l7�G/�.F- J
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INSTRUCTIONS: See ieverse side for filing instructions. �n �� � ' �a� ,�� '
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� N`'e) �` P certify that I(we) occupied as my (our) prindpal
place of residence or am (are) buying following described real property (or which a Ho es ad Property Tax Standard Deduction is hereby daimed
under mnVact on Ihe date Nis applica on is (led, (date o/filing):
�(We) own ❑ Am (are) buying under recorded conVact
Am (are) enlitled [o occupy as a tenant-srockholder of a cooperetive housing corporation
� Have a beneficial interest in the irust or the right to occupy Ihe property under Ihe tertns of a qualified personai residence Wst
1f buying om m�bact, Fee Simple owners name
Remrtlets of6ce where mnVad is recorde0
Caunry
Township
Other number
of daimant (lasl !rve tligks)
Drivefs Grenu / Identifratian / Othe
of daimant's spouse (Wst frve dgCS)
���� pir�
Remrd numCer Paqe
(rily, town, township)
/ • Ivrv� 2
Parcel num Lcgal tl 'D� Q Is Ne pmperty in puestion:
' D ] � ❑ Real property MnuaAy assessed mobile home (IC Gf. f-7)
of Me � �� �eniial svucwre or Ne WM na ex ueg me (1) arre that immetliatey swrourMs that swcwre is u w proeuce iMOrne, dewioe tne use and porcion
nY P�oduce iMame. �/ �'� � / :i �O
d�-i-,-c�s�-�_cYS-�S- oio-Ga1
��
Township
I hereby certify the above statements are We, correct and complete.
Adtlress (numberand sLee( pty, state, antl LPOOde)
Land notexceetling t�one)acre
Other land
Total land (line 1 plus line �
Residential improvements or Mnualty �����9
0.ssessed Mobile I Manufactured Home Garage
Other improvemenis
Total Improvements (line d throug� line �
Total value (Ilne 3 pf�s I/ne �
I here6y certify the above is trae, cortect,
and complete.
Vaitying action - Sgnature oflwtlitw
sv�l/P 3n 'i��(oS
n)
�2)
(3)
(4)
(5)
(6)
��)
(8)
Signatura atASSessor
20 pay 20 Lesser of 60% of the assessed value of the homestead or $45,000
NofwiNslerMirg eny otherpmNSion, Ihe sum ol the tledurliwis providetl in IC G 7.7-12 to a rtroEOe homa /haf is
mt assessed as real property or to a manufarlured hwne Nat is rrot essessetl es mal pmperry may nof erceed
one-hatl (1R) ol Ne assessetl rdlue ol the mobrle fwme or manu/aflured hwne.
S
Tow�v4dp
Dace signed (mrnfh, day, yse�
Dace
Oate signW (monM, day, yea�