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CLAIM FOR HOMESTEAD PROPERTY TAX
s. ._rt' '; STANDARD / SUPPLEMENTAL DEDUCTION
StetB Fortn 5473 (R72 /6-09)
�� � Presai6ed by Ihe DepaMrenl of Local Govemmem Fnance �
INSTRUCTIONS: See raverse side for �ng instrucfions.
u �- h
FORM
HC70
�
YEAR
I M'Q) �� V �.f:(,(�/� certify ihat I(wne) ompied as my (our principal
place of residence or am (are) buying the folbwing described real prop for ich a Homestead Pmperty Tax Stanry�� Ded�clion�s,�by daimed
under conVaa on the date lhis a lipiion is filed, d
P� (date o/filing):
❑ I(We) own ❑ Am (are) buying under recarded contract `,
❑ Am (are) enti0ed to occupy as a tenant-stockholder of a cooperative housing corporation r��p �7a"` �`
� Have a beneficiai inlerest in the Wst or the right to occupy Ihe pmperty under ihe terms o( a qualified pers$flfvq��q�tpi� ,_
Name
+.'^.^I
name)
II Mrymg m con7act, Fee Simple owneYS riame
RemNefs ofGCe wtrere mntrad is remrCeE
Counry
m aa�,wm �wu r� e;�
o�rs i��e i me�w�u� i an�
ot daimem's spouse (las! Pve digifs)
Te�g
i�,�y sa�
Record numCu
Is Ne pioperty m pu�tion: Q ..
Page
V-i.�� i h l00(O'-�/ UI � LI'�a� 7�PertY U MnwOy essessed moL'le twme IIC bf. f-7)
swcwre or tne land rot exceed'ug rne (t) aae �hat 6rvnedlatey wrtauMS that smxa�re is used ro woduoe incame. Easmbe Ne use arW portbn
rce inmrtre.
Township
I hereby certify the above stetements are true, comeU and complete. '�'�'
AOOres (numberands! t,ciry, te,andLPCnde �
o!�3a� b� foS�o 4, , bWENSUIU..�, �I11
Land nat exceeding 1(orre) acre ImmeAlatey
surtountling re5ldential improvements.
Otherland
Total land (line 1 plus line �
ResldenUallmprovementsorMnualry �Iiing
A.sessetl Mobile I ManWactumd Home Garzge
OUer ImprovemeMs
Totnl improvemenb (Ilne I fhmugAline �
Total value (Ilne 3 pl�c line 7)
I hereby certity ihe above,is [rue, tortecl,
and tomplete.
Veifying acbon - SignaNre of Auditor
��)
(2)
(3)
�4)
(5)
(6)
(B)
SigriaWra of Assessor
20 _ pay 2(1 Lesser of 60% of the assessed vaiue of Ne homestead or $45,000
AbMlMsfaM6g eny aNerprooision, Ne sum d�he deductuns prm�idrd in IC 61.1-f 2 to a rtpW]p fpme Nat is
not euessed as ieal proprlly or lo e manutaUUred home Nal "a nof essessed es real pmperry may rpt eYCeed
�
5
S
Twrt�ship
Date WgneE
Datc signed (month, Eay, yearJ