Homestead_Ellis ;} - CLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR I
.. -. : STANDARD I SUPPLEMENTAL DEDUCTION HC10
v State Form 5473(R15/5-14)
=' Prescribed by the Depatnem of Loral Govemmet Finance
INSTRUCTIONS:See reverse side for filing instructions.
NOTE:Telephone,Sacral Security,driver's license,eats identification and federal idenaication numbers are confidential under IC; I -1 137.)
Y'1 ,-•._: .' ' 1_7.- _ '• .CERTIFICATION STATEMENT"r v,. - 1 T�,'3i t t 'f'-- 1 ',i
I(We) 4 , �Lt r../ ii x certify that I(we)occupied as my(our =0.
place of residence or am(are)buying the following described real property under contact for which a Homestead Property Tax Standard
Deduction is hereby claimed on the date this application is signed, (date ofsignatt. R 014 2016
❑ Own. ❑ Am(are)buying under recorded contact.
❑ Am (are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation. •
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a qualif,CD�d rso.: ".::.•a: 4 =�'
❑ Am (are)the shareholder, partner, or member of the entity that owns the property. GI $ON COUNTY AU II;TOR
'
:`___ _.
If tying on corral.Fee Simple owner's name
Recodets o5ce where contract is recorded Recond number Page
s -'' ERORERT,Y,,DESCRIPTION- — �"s 'AFT°—'• '�'' � 'mow+ '>
Corny Township Taxing dsSi fogy,town trams*) f
1 Parcel number Legal :pion Is the property it euesliax
nd1/tom//Q,"�,/` ��f�j�� ❑Annually assessed mobile home(IC 6-1.7-7)
if any portion of the reside:tal sou=re or the la at exceedng ore(1)acre Mat immediately sr' n:unds that smudure a used to produce income.descibe the use and porlim
of the property 1.3ized to produce income.
c, -/v- is - 4a 3 - 0o /. 3 3G - 0b 7
' _ :.PROPERTY.OWNED ELSEWHERE BY CLAIMANT,. ' - .. ,_-._, •
State,Candy,and Township Is claimant vacating a homestead?
. ' ❑ Yes ❑ No
Sipes; f da'enare
I hereby certify the above statements are true,correct,and complete.
PCi'\ Address of contact(member end street ay,state,and ZIP code) I of vacated ho �t%y Mare,aced ZiPmde)
. :ASSESSOR USE ONLY ASSESSED VALUE I HOMESTEAD VALUE'. 'I , NON-RESIDENTIAL ,
VALUE
Land not exceeding one(1)acre Immediately I --- - —,`
surrounding residential Improvements (1) _ — __:. __.-.•. c.... :._.
Other land (2) t
Total land(line 1 plus line 2) (3) -
Residential improvements or ' Dwelling (4) - ?Y' " ' :
Annually Assessed Mobile I _,
Manufactured Home Garage I(5) -
d r ��.
Other improvements (6)
ITotal improvements(line 4 through line 6) (7)
Total value (line 3 pits line 7) I(0)
I hereby certify the above Is true,correct, I Signature of Assessor Date signed(month,day,year)
and complete.
1 Vedyvg action-Signature of Data signed(month,day year)
,tee xL"?;'- .fte°, 6'Pi.:STANDARD DEDUCTION ALLOWANCE y" u �°+i'>T -"
20 pay 20 Lesser of 60%of the assessed value of the homestead or 545.000
Nohsithstandug any other provision,the sum of the deductions provided in IC 6-1.1-12 to a mobile home S
that is not assessed as real property or to a manufactured home that is not assessed as real property may
not exceed one-half(12)of the assessed value of the mobile home or manufactured home.
Sgnt se of Audor Data Signed(t t day.yew)
'A /�/
DISTRIBUTION: :tor, r