Homestead_Ice (6)/^ CLAIM FOR HOMESTEAD PROPERTY TAX
;t,�,. � STANDARD / SUPPLEMENTAL DEDUCTION
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Suta Fortn Sd73 (R12 / 6-09)
�+ � Presttibed by the Departmeni of Local Govemment France
INSTRUCTIONS: See ievarse side !or filing instructions.
' / FORM YEAR
V HC10
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�• certify thaYL(s� �r my (our) prindpal
1 I (We)
place of residence or am (are) buying the following described real property for which a Homestead Property Tax Standard D io i hereby daimed
under mnVact on the date Ihis application is filed, (date ol(ling): G�gSON COUNTY AUDITOR
_❑ I(We) own ❑ Am (are) buying under recorded contract
❑ Am (are) enGtled ro occupy as a tenani-stockholder of a cooperaiive housing corporation
� Have a beneficial interesi in the imst or the right to occupy the property under lhe terms of a qualified personal residence wst
name)
f dau�iro7m (bsl frve dg:ts)
a (legal name)
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ol daimani's sp se Qast frve Op
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�ImPle�–a y��'
(�J
Dmrers ficense / Identif'Cation �
of daimant (Ws( frve tlg2s)
of daimanYs spouse (�as1
(city, town. tON'�iP)
Caunry — ...._ . �
Parcd num6er legal dcsriiP�n Is Ihe D�oPenY � �U°^:
as i
6��� �- O 5 00 -DO �d �' ❑ Rea1 vroceM
��� �( yry pprtion ol Ne residenUal swcNre w Ne land not axceeEing one (1) acre U�a1 unmeEieteN surtounds Nat sVUCWre is useE
ot Ne P�PQnY ulilizetl to produ� fnmme.
�v
�'l�
Township
I hereby cerUfy the above statements are we, rnrtect and complete.
aM
Wnd not e:ceeding 1(one) acre immediatety
s rt u d'n9 resitle tial improvements.
Otherland
Total land (line 1 plus line 4)
Residential
ASSPS52C N
Dwelling
Garage
Other improvemenu
Total imp��ements (�1ne 4 fhrough line �
Toul vatue (line7 pl�s line 7)
I hereby certify ihe above is true, cortect,
and complete.
Veilyin9 ad'an - Si9riavre of PLdrtw
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(2)
(3)
(4)
�$�
(6)
(�)
(8)
Sgnature
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Counry
��t��10
20 _ peY 2� — �esser of 60% of Ne assessed value of Ne homestead or $45,000
ryWwilhstanEirg any Wher p�oNs.on, Ne sum o/ the detluc+lona Pro�*ded i^ �� 6'�. �-�2 �o a rtro6➢e frome Ihai is 5
rqt assessed es real property w lo a menufeUUrad hrnre Nat is rat assessed as realpropert}' /naY ^�t exceed
. . ,.." _'..�_ ......e ,...ti„�T rtured horne.
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Issuing Sta;e //
�y�
Issuin9 State
R d number Pa9e
wJ
� e wM a. ed rtrodle home (IC
Daee sgned (mmth, day, year)
Date signed (monlh. day, yea�
signed (monN. day. year)
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