Homestead_Bellinglert
CLAIM FOR HOMESTEAD PROPERTY TAX YEAE
i � STANDARD I SUPPLEMENTAL DEDUCTION FORM
5•r.eFOrmSa]3�R15/Sta) HC70 /�j �
'���' P�esaibeEbyNeOepanmentofLOCalGOVemmer.tFUUnre
INSTRUCTIONS: See reverse side lor filing insbuclians.
NOTE: Telephone, Sodal Securrty, tlrive/s Gcense, sfate itlenli;calion aM fede2l idenfi.5catron numbers a2 wnfitlen;ial uiMer IC .-i2-
I(We) certify that I(we) ocwpied as my��pu�) �nd{
place of residence or am (are) buying the following d real pr under contraa for which a Homestead Property Tax SanGe
Deduction is hereby daimed on the date ihis application is signetl, (date oI signature ly� (VJe):
/ // n
❑ O+m. ❑ Am (are) buying under recordetl contract. XId70A.��N
❑ Am (are) en;itled to occupy as a tenant-stockholder ot a cooperative housing wrporation. GIBSON COUN71
❑ Have a bene5cial in;erest in Ne Wst or Ne right ro occupy Ne property untler Ne terms of a qualiLed personal residence w�
❑ Am (are) the shareholder, partner, or member of the entiry that owns the property. �
, � u a+
oi tlaLrant
mn:raa is recorEN
��
[
nvrW
Pxge '.
County TawnaNp iaung Eis ' ., tonn, tom�ship) • i
Par¢IrwmEer L � qn II U�epropertyin9uestion:
�IYOcerY ❑AmuaNasussMmodbtwr.ief/CS1.1-]�
tt anY Gabm of tte resi4rc.ial s7uaive w Te Urtl mt ez me (t) ave Wt vnr.cCiYSly w�muMS t�at Y.iwive is useE m P'mus'umx. aesc�:Je me �ae arcl �
m� O�cerY v.daeC ro yoEUre income. '
a�_���aaQa 7�. �3�-6a� '
Sa:e, Coumy, am Tmverstdo I Is tla"unant vdra�ng a hwnesteatl?.
❑ Yes ❑ No �
I hereby certify Ne above statements are true, cortect, and complete.
�m�acm,�,�ec�cas�r�.re.a,�ev��� .O,1bF Y9
�0�1 E./�joe�u�eN�Sf,Qwev�s ✓�lw 1�1/. 4 �GG 5
OtherlanE
Total lantl pine f plus line S)
Resltlentlal Impmveman6 or Dwelling
Annualty Assassetl Moblla /
Manufach�rad Nome Ganqe
ONer improvements
Tobl im0�ovements (line d Nivugh line 6j
Total value (line 301is line 7)
1 hereby certify �he aEOVe is W e, correct,
and complete.
Va:ryg acion - Synavre W Nkimr
(3)
(<)
(5)
(6)
(8)
20 _ pay 20 _ Lessero! fi0% of ;he assesse0 vrJue o: Ihe tromestead or Sa5,000
NoM1Ui(hstantling any otherpmvisioq the sum o/ lhe tletlucUons provided in IC E f.142 (o a rtrobile frome S
Naf is rrof assessed as real plaperry w ro a manufaclurtH home thaf is nof assesretl as realpmpeM may
rpf exceed one-ha7(12) of fhe assessetl vaNe o1 Ne rt+obrle l�ome w manufaclured home.
OISTRIBUTION: Otginal - Counry AW�tw, FOeStamped Lopy - Tazpaytt
ar, rae. �a
Ws slgrcC (rtmn.
OYS si9reC (mmll�.
I,:
�� �