Homestead_Hall •
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STATE LBW 51569(R2 I"A) TREASURER RAM TS-SA
APPROVED BY STATE BOARD OF ACCOUNTS.5W9 FRESCRaIEO BY THE DEPARTMENT Cf LCCAL GOVERNMENT FUSA\LE C6-I.I 1:-!.I
IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS
Individuals and married couples are limited to one homestead standard deduction. As the receipt of this
deduction becomes more beneficial, there is more incentive than ever for homestead fraud. Homestead
•fraud causes higher tax bills for all; therefore, HEA 1344-2009 requires taxpayers who receive the
homestead standard deduction to verify that they are eligible to receive the benefit and to provide
additional indentifying information necessary to allow county government to better monitor homestead
filings. This information will be kept confidential and can only be accessed by authorized county officials.
The Department of Local Government Finance will use this information to create tools that will help
county officials eliminate homestead fraud.
PART 1: PROPERTY INFORMATION
Property Address(number and street,city,state,and ZIP code) : •
yo5 0.420 Ck
�7b7d
State Pared Number
a a-/OR - J - 070 3 000 T4 . Et
OCT 2 8 2013
PART 2:TAXPAYER INFORMATION
Owner I ' First Middle GIBSON CO I I I
Oren 4
N //
Mailing Address(number and street,city,state,and ZIP code) n Same as property address
/
Spouse First Middle Last
Mailing Address(Number and street,city,state,and ZIP code) ❑ Same as property address
Social Security Number(last 5 digits) Driver's License/State ID Number (last 5 digits) Other(please specify in Part 4 below)
Stale
• PART 3:CERTIFICATION
Each undersigned certifies,under penalty of perjury,that the above and foregoing information is true and correct and that he or she is
eligible to receive the homestead standard deduction on this property. Each undersigned also understands that,by claiming additional
homestead deductions unlawfully, he or she may be liable for back taxes and substantial financial penalties.
Owner I Sign �ed M Date ��
INSTRUCTIONS
gn EX
CLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR
CREDIT/STANDARD DEDUCTION � HC10
9-1.5
State Form 5473(R6/4-03)
Prescribed by the Department of Local Government Finance \\-)
INSTRUCTIONS:See reverse side for filing instnmtiorrs.
Olirri t..t :L..a#` ±., " .ffiege"t'•Sac::' ?x,;CERTIF,IC l_ON STATEMENTir.'',e ` L :` ..
r
I(We) A I' j # ha `tI / certify that on the 1st day of March,20 •
I(We •ccupied as our principal place of residence the following descried real property for which a Homestead Property Tax Credit is hereby claimed:
■! I(We)owned ❑ Are buying under contract
Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns the property or is buying under a contract.
.`i-.71-i atURW ah ,5a£el fIS—Pr -s~y1,'i` .CONTRACT.'RECORDED=,t.Y',sct,,,dq +,,y�h � ' F'.�". t-" `
If buying on contract,Fee Simple owners name
Recorders office where contract is recorded Record number Page
gra411r.,t:�. o?-„t,'t„t a -'' - -:.r?PROPERTY.,DESCRI •N 4-ti -ila .,.x
County Township Tar g ir (city,town,townshi )
✓t02(10 /K
Pore!/gberQ� Legal descriptia - d Is the pmpert in question:
/ _ terry ,`-G�CJ `/�J-uJ-awl/ rVIL/Real property ❑ Mobile Homo(/.C.6-1.1-7)
If any portion of the residential structure or the land not ex ing one(1) cre that immediately surrounds that structure is used to produce income,describe the use and portion
of the property utilized to produce income. / � pJ/1 q
2-1,0 -/ r_2*•.;;.}`W
County Township County Township
I hereby certify the above statements are true,correct and complete. Signature of claimant
Address(number and street,city state,ZIP code)
• �9 5 oxv /t„„v Trnt -976 7
; §YA ESSORi E ONLYi , VALUE,. AT E00%'OFTiYHOVALUTEAO tNON VALUE$i IAL - _
i3PAi'l:S Milli & > .�as ane . _- ,'.��- ow F._. '&t . ...m iu a '..-., a,E
land not exceeding 1 (one)acre immediately
surrounding residential improvements. (1) '�” rs 'a vi;g.:"`
k: u- asa
Other land (2) y `
Tctal land(line 1 plus line 2) (3) {{ ��.,�..rx
Dwelling (4) r'fec*le,
ResidentiallmprovementsorAnnually -
Assessed Mobile/Manufactured Home
Garage (5) f Y 1,_.3�. -
Other improvements (6) .– "S'" .,r= '3
Total improvements(fine 4 through line 6) (7)
Tctal value (line 3 plus line 7) (8) •
I hereby certify the above is true,correct,and Signature of Assessor Date signed
complete.
Verifying action-Signature of Auditor - Date signed
tea" ,'. fejaa ? - ,';e,'S:trO STANDARD:'DEDUCTION'ALLOWANCEgrr k�;.y{ MW'jt'" "y.y -�`
,:_-�. .._� sue
20 Pay 20_
Lesser of 1r2 Homestead $
vauation or$35.000
Signature of Auditor Date signed