Homestead_Pennera�
"'" CLAIM FOR HOMESTEAD PROPERTY TAX YEnR
i_. ; STANDARD / SUPPLEMENTAL DEDUCTION HCRO
'� .: $tate Fortn 5473 (R72I6-09) .
�O ,,� % Preuribetl by Ihe Depanment of Local Gwemment F`ance � �
INSTRUCTIONS: See reverse side for filing instmctions ' �
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I(VJe) certify ihat I(we) occupied as my (our) prindpal
place of residence or am (are) buying the following tle � ed real property fw which a Homestead PropeAyY�c.$tandard,p clion is hereby daimed
under VaA on the date this applipUon is filed, (date ofllin ���a"}i '�S�
9) V
I(we) own ❑ Am (are) buying under recorded wnvaa d�BSON COUNTY AUDITOR
❑ Am (are) enUtled to occupy as a tenanhstockholder of a cooperative housing mrporation
� Have a benefidal inlerest in �he Wst or the nght lo occupy the pmperty under Ne tertns of a qualified personal residence Wst
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Nama ol daimant (legal name)
Sodal Seamty af nt b5 fi�e d'gis) Orivels lirense / IdenUficetlon / Other number Issuing State
name)
Sodal Seariry nu of UaimanYS spouse (last fiva dg'rts) Dmrers ticense / Idrntifitation / O� ��� Iswing State
ot da'unanfs spouse pest (rve dg2s)
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If buy'uig on rvntracf, Fee $imple owneYS name
Recortlets offi� where convscl is remNeO Reeord number Page
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Caunry Townshi7 Tatirg G�sviG (tiN• town, townshiP)
Pamel number legal0 " tion 1/O 1� Is Ue D� �+Quesiion:
� - o .3 a o•-� �}�' a� G�VeM ❑�nua0y essessed rtabile home (IC fi-7. f-7)
� 1f any portbn of ihe msidentlal sWCW�e or Ne WM not erceeding a�e (7) arne ihat immediatety surraunds ihat swcwra is useE to produce Nmma, desrnbe Ne use aM portion
ol Ne property wTaeE m produce inmme.
(
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Counry Township County Townstdp
I hereby certify the above statemenis are we, corted and comptete. Siy wra oi dalmant �
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Address (number aM sUeef, ary, state, entl Z/P mtle)
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Land not exceeding 1(one) acre immediatety ry�,{� 'y'_ �.�'�?="��z° ��-� -�-�
surroundin residentialim rovements. (�) `t:`_-=v�-.._-r�`^-��r=-�`%ti:•r.���.-�:�ui
Other land (2) Y��"? s"�bp?�-s3
Tofal land (line 1 plus line � (3)
Dwelling (4) "4t"�"���...c�rar x -��t'?�S--k-r
ResidentlalimprovementsorMnually "�� `- a . �� �` �
Aueued Mobile l Manufactured Home �� {"` l'.F'�` °.�Z}+1a� ri ��i''"
Garage (5) - J^::. '�i� ��.��iL+�`iis,`�;+°�Y
� r �� �� �,� �:'.
Other improvemenb (6) x<_
Total Impmvemen� (/(ne 0 Nrough line � (7)
Total value (line 3 pl�s 1(ne 7� (8)
1 hereby certify lhe above is true, cortect, Signanire ofAssessor Date signed (mrnth, eay, year)
and complete.
Vaifying action - Signature d Auditw �� 59� (^b^�. �Y. Y��
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20 _ pay 20 Lesser of 60% of the assessed value of ihe homestead or $45,000
Natwi(hsfaM"ug eny olherprovision, Ne sum ol fhe ded�xt,bns provitleO in IC 67.1-72 to a mobde fame Ihaf is g
llpf853BSS8.'�d51B8��NP8l�}'OlfOdlI18PU:8UIIIB(��IORIB:118f6(10�85585SB(�dSRBIplDQClfj�rtNyllOfBYCBB'J � " '- ' - —
onedaH(f/1) 01 Ne asseueC value ol the mobie Mme ormanuYdrt�retl home.
Si9naWre af PiWtlor Date signeC (rronlh, day, yEa�