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.�=CLAIM FOR HOMESTEAD PROPERTY TAX FoRM
i., STANDARD I SUPPLEMENTAL DEDUCTION
Sb:e Fortn Sa�3 (R151 Sta) HC70
�� PresmOeC by Ne Depafiner.t o: laml Gove�t Fiu�
IN$TRUCTION$' $BBlBVB/SB SiAB /OlfillnSlNSIN[fuf15.
NOTE: Teleohone. Social SecunN. tlrivers license. sfate itlenGficauon aM fede2l itlentificaGOn numbers a2 confidenGalY7�Z$l376Rf-
I(VJe) C certify Nat I(we�ocwpiLd�d� (d67'J
place of residence or (are) buying Ne foliowing described real property under conVact for which a Homes:ead Pmperty Tax
Deduction is hereby tlaimed on the da;e Nis appliwtion is signed, (date o�ty�). I�
❑ O.m. ❑ Am (are) buying under recorded convact.
❑ Am (are) entitled to occupy as a tenan4stockholder of a cooperative housing wrporaUon. ,
❑ Have a beneficial interest in Ne wst or Ne right to occupy ihe property under ihe tertns of a qualifi
❑ Am (are) the shareholder, partneC or member oi the entiry ihat owns the pmperty. (i�8$ON COl1WTV .
mmtEer
II ❑ 0.ea1 prope .ry � Mnwly as5esseC mo0ie twme (� 61.1-n
u a^Y w�'uon o1 tne �esilen'Jal svucwre w Lhe Wm rot ezaM�a�q ax (f I ave c^.a� i.—mMa•.eN weroundti Nat sTiclre ¢ useC W P�� vmne. Cesc:�e c�e use anGlpution
cf Me W We�Y �OE b R�uce �nmme_
a�-/�-0 9 -aoo-ooy. 9,9_0�l
��,�..�r�o
1 hereby certify Ne above siatemen5 are true, cortect, arW complete.
S�IC:ess ot cmaa NumGxerM SreeL �NY.Sa:e. ard LPmOe)
acre
Otherlana
Total UnE (line 1 plus line 3)
Resitlential improvamenb or
Annualty AssesseE Mobile I
ManufacWratl Home
oue.
o�.emnq
Wnga
Toial improvements Qine 4 fhrough line 6;
Tofal value (linc J pllc line ])
I hereby certify Nn above is We, cortec4
and <omplete.
Ia.}ig acia� - SgNN!! OIP�tl,:IX
(21
(3)
(4)
(5)
(6)
20 _ pay 20 _ Lesserof 60% of the assessetl value of tt�e hanes:eatl or 545,000
No�tiNSfantlirg eny oiher pmvivon, Me sum ol Ne tleductbns pmveled in IC G iJ42 ro a moblle home 5
Nat is rrof assessetl as real pmperty or m a manu(aGUred horrie Nat is nof assessed as real pmperty may
rrot erceetl one-ha7(1R) o( the assesseE value o(fhe rtroble lrome wmanufaCUreC hwne.
:r_:u^..,re maie::cr
DISTRIBUTION: Otqvul - CoutCJ AW br, Fde�Sam�eC CopJ - Taqayer
tlaimant vantlng a
� Yes Q No
oa:e v9nea (rm.h.
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