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""� CLAIM FOR HOMESTEAD PROPERTY TAX
� STANDARD/SUPPLEMENTAL DEDUCTION
ir State Portn 54)3 (R72 / 609J
�O ` Prescribed by the DepaMcenl of Local Goremment F�xe �
INSTRUCTIONS: See reverse side for filirg inaWGions.
� FORM YEAR
�� ° 201
C.�."`�""�`""�
I(VJe) certiTy that I(we) occupied as my (our) prindpal
place of residence or (are) buying ihe following desaibed real property for which a Homestead Properry Tax Standard Deduction is hereby daimed
under mntraa on Ihe ate this appliratlon is filed, (date ol filing):
❑ I(We) own ❑ Am (are) buying under recarded conVad
❑ Am (are) enfitled to occupy as a tenant-stockholder ot a cooperetive housing corpo2tion _
� Have a beneficial interest in Ne Wst or the right to occupy the property under the terms af a qualified personal residence Wst
at tlaimant (last INe d'gifsJ
Seartiry mimEU ot daimanYS spouse (last fiue dig'RS) I Orive/s ficeree I ICentification / ONer m�mber
ot daimanPS spouse (/as7 five C'giGCJ
II Wying m contract, Fce Simple owne/s rame
Rem�dels otbce where cmtraG is remNeG
Counry iownship
Iisvmg $tata
Remtl numbv Pege
_
lown, (own.VtiO)
PafceJ number �Mal Ae^ai0tion a. y ys -¢ c Is Ih perty in ques
' s F ' a�� �, Real property � AnnuaCy aASessetl modle home (IC 6f. f-�
� ot ihe p�ioperiyaW e�� p�u� c��rere Ne IarM not exceedifg me (1) aae Ihat immediatety surtounds that sWC4rta iv used In pmduce Incama, descnbe Ue use and portion
a6-10-3�-��/-ooy, �-oa/
�
Counry
7ovmship
I hereby certity the above stetements are We, correcl arM compiete.
� AEAress (num6er antl sLee4 �l: sta:e� and LPCOa
� � �
. �- �
LanA not e:ceeding 1(one) atre ImmeCiatey
surrounding residential improvements.
Otherland
Total land (line 1 plus line �
ResldenUal improvements or M
Assessed Mobik / ManutacYUred
Other Improvemertts
Dwelling
Garage
ToGi improvements (line I throug� Iine 6)
Total valua (llne 3 plls line �
I hereby certify the above is We, correct,
and complete.
Vaifying action - Signature of PLQitw
(�)
(Z)
(3)
(4)
(5)
(6)
m
�8) '
Signature Of Pssessor
Caunry
$ignaNrO
20 pay 20 _ Lesser of 60% of Ne assessed value of Ne homestead or 545,000
NaMbhstardrtg eny oNerproeision, Ne sum o1 the deductiau proYtldM in IC 61.1-12 to a rtmbde hwne Naf is g
rrot esseueG es �eal properry w fo e menufaGUied hertie Nat a rof essessed as real property maY not erceetl
onHUtl (iQ) o/Ne assessed velue o7fhe mobde homa wmanuFaUUred hortie.
Sg��o��T.
TownsNp
Date signed (rtimlh. dey,
(monfh, day, year)
Date signeE (mm(h, tlay, yea�