Homestead_Keen""" CLAIM FOR HOMESTEAD PROPERTY TAX
s _ � STANDARD / SUPPLEMENTAL DEDUCTION
Sfale Fortn 5473 (R72 / 649)
° � Prewibed by the Departrrerrt of Lowl GovemmeN Frexe
INSTRUCTIONS: See ravarse side fw filirg instruc(anz
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OCT 2 9 2010
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I(V✓e) `f� LQ � ,�LSj,r.J certify that I we1 �cwpie s mY ( Prind I'
place of residence or am (are) buying the foliowing desuibed real property for which a Homestead Property Tax �ndald'DeaaCUtl�Xe�iy�ed
under contraa on the date Ihis appliption is filetl, (date of filirn�): �
I(We) ovm ❑ Am (are) buying under recorded contraa
Am (are) entiUed to ocwpy as a tenant-stockholder of a cooperative housing corporetion
� Have a benefidal interest in the wst or the right to occupy the property under ihe terms ot a quaiified personal residence Wst
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Name of t (kgal name ' ��
Soda� Se¢mty ruc�ber o( ' (!aC fie dg3s) Orivers �icenx / Idnntifimtion/ /�
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Nama of s ^sp��ws,e (lepal name)
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Sotial Secunry numbri ot daimanYs
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II buying on wntract, Fee Simple owners name
Remrders atfice where conirad is remtleE Record number Page
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Counry Trnmship Te�ur9 A� (�iN. to , MwnshiP)
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Parcel number �egal desaiP� , Is Ne P Vuestion: �
� Real properry � MnuaOy assessed mo6ile Inme (IC Gf. f-7)
1f any portion of Ihe retidentlal sWCnire or Ihe IarM not exceed4g wre (1) acre that Immadiately surtoun s that strucWre b used to produce i�oma, Eesaibe the use antl portion
� of Ne Pmperty�lP � �� v � � QQ � �• / / / � D �/ .
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Cw�mY 7ovms�iP CaumY - Towrahip
I hereby certify ihe above statements are true, corteU and complete. Sgr�gmre daimant . �
Pdtlreu(num6erandstreet,oly,state,antlLPCOae� � � .. ' V
4J. 55o S "�e� u� 1 �E. ?—�J . �f �(�(n S . .
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Land nm exceeding 1(one) acre immediatey -�i,���-�. �rr .�._ �
surtoundin resltlential im rovemen�. (�) 's�r "u ,`",a�"J�`t,����.#.,F-�,
ONet land � (2) ��(�� �i �
.-,_.fi:s�3"+.��'l .
Tofal land (line 1 plus line � (3)
Dwellin 4 `'.'Y''`+�3r"� �.��'�,-'y;�i1�'���
Resldentlal Improvements or Mnually g �� :?•- : T.k% a- At,�z._
Assessed Mobile 1 ManuFaca�retl Home �� ?..�t'�3^ d�'.»�� ��:
Garage 5 ...ssY��{£ a.�'T�3i�.�.�.�». ';;�.:
Otherimprovemertcs � (6) :�?�:_�v(��',4�"'ti�.�t'`;
Total improvemen6 (line 1 through line � (7)
Total value (line I pf�c line 7) (8)
1 hereby certify the above is We, wrrect, Sig'uwre otASSessor pate yg�etl (mp�th, day, yea�
and wmplete.
Vaifyim� amon - Sig(ature of PL6ta . ' Date signed (rtronth. tlaY. Y��
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20 _ pay 20 Lesser of 60% of the�assessed value of Ne homestead or $45,000
AbMithsfaritling any afher ryoWVOn. Ne sumW tha deducfions prwidetl in IC &1.7-12 fo a rtm6de home Naf fs $ -
notassessedasrealpropertywfoamanWxturedhomeiha('snotassessedasrealproperrymaynoferceed . ._ . -
oneJiatl (72f W Ne assested value d(he mobda home ormanufarluretl hortie.
SignaWre of NMhm Date signeE (mdtlh, day, ysa�