Homestead_Simmons 'Reset Form'
-ti CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
• 4i•ito. ISTANDARD / SUPPLEMENTAL DEDUCTION rFORM r State Form 5473(R20 12-24)
Prescnbed by the Department of Local Government Finance
HC10 .
�" INSTRUCTIONS See reverse side for piing instructions
NOTE Telephone Social Secunty, dnver's license state identification and federal identification numbers are confidential under IC 6-1 1-12-37
S•\1?)? j..-• w CERTIFICATION STATEMENT
x I (We) ` � 11161 •NS* certify that I (we)occupied as my (our) principal place of
�' ` residence •r a, (ar- • ying the following described real property under contract for which a Homestead Property Tax Standard Deduction is hereby claimed on the
C date this a.. ation is signed (date of signature) I (Wei
��[jJ`T" sz>)\% * Li Own ❑ Am(are)buying under recorded contract
Li Am (are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation
cr414
Have a beneficial interest in the trust or the nght to occupy the property under the terms of a qualified personal residence trust
Am(are)the shareholder partner or member of the entity that owns the property
CONTRACT RECORDED
If Buying on Contract, Fee Simple Owner's Name
Recorders Office Mere Contract is Recorded ' Pe-7Fr!' .,-”tier Page
PROPERTY DESCRIPTION
County �OY \ Township O 2 \ _ I Taxing D,strx:t(crt tag:•:•
(`\}xi)
Parcel Number Legal Description I h property in question
Real Property Li Annually Assessed Mobile Home(IC 6-1 1-7)
If any portion of the residential structure or the land not exceeding one (1)acre that immediately surro d that structure is used to produce income.descnbe the use and portion
of the property utilized to produce income
2.1 . 6 2--Lk - 02___ .
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State County and Township Is Claimant Vacating a Homestead?
Yes ❑ No
Sign. - • laimant
I hereby certify the above statements are true, correct, and complete
_--
Address of Contact(number and street. city state. and ZIP code) Address of Va ed Homestead. if any(number and street, city. state. and ZIP code)
0 6�AI SOO S O v,11 - v) I -6 6
ASSESSOR USE ONLY ASSESSED VALUE I HOMESTEAD VALUE NON-RESIDENTIAL VALUE
Land Not Exceeding One (1)Acre Immediately (1)
Surrounding Residential Improvement
Other Land (2)
-
PI-4
Total Land (line 1 plus line 2) (3) J
Residential Improvements or Dwelling (4)
Annually Assessed Mobile/ -- --
Manufactured Home Garage (5) - ,t0
Other Improvements (6) 01/ /
Total Improvements (Line 4 through Line 6) (7) S
—: ' N'. .\
•
Total Value (Line 3 plus Line 7) (8) ale
Signature of Assessor CO Si fie date month. year)
I hereby certify the above is true, correct, and complete. 64/ '
Venfying Action-Signature of Auditor Dale „V h. year)
/
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STANDARD DEDUCTION ALLOWANCE
20 Pay 20 Lesser of 60% of the assessed value of the homestead or S48 000
Notwithstanding any other provision the sum of the deductions provided in IC 6-1 1-12 to a mobile home that $
is not assessed as real property or to a manufactured home that is not assessed as real property may not
exceed one-half(1/2)of the assessed�e-oh4LT mobile home or manufactured home
SFtyc� f dor Date Signed( nth da year) —
� Y � sl � ^
DISTRIBUTION: Original-County Auditor - tamped Copy-Taxpayer
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