Homestead_Stewart^•n
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CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD/SUPPLEMENTALDEDUCTION
Stata Fortn 5473 (R12 / 6-09)
PrescnbeA by lhe Departmen� of Laal Govemment France \
FORM YE'�
(� HC1
\ \ O ` �
INSTRUCTIONS: See reverse side for filing instruclions. � O
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I(We) � cenify that I(we) occu s my (our) prindpal
place oF residence or am (are) buying the foliowinq described real property for which a Homestead Property Tax ��6�is hereby tlaimed
under vaa rn the date Nis applica6on is file4 (date o/ filing): G�BSON COUNTY AUDI7�R
(VJe) own ❑ Am (are) buyinq under recorded conVacl
❑ Am (are) enGtled to occupy as a tenant-stockholder of a cooperetive housing wrporation
� Have a beneficial interesi in the Wst or the right to occupy the pmperty under the tertns of a qualified personal residence Wst
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Nam tla' nt(legalname)
Sodal Seanity nunber d t(Iac1 fi�e dg3c) Ofivers Gcense! Identikaiion /
Sotlal Securiry number ot daimanCs spouse (WSf five digds) Drivers Iirense / IdentiflraGon / ONer number Issuing State
of daimanPS spouse (lasl five d'gifsJ
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If buying on contracl Fee Simple awnefs `ame
Remrtlefs otfice where conVarl is remrCed Remd numbu Page
..�. . � . �
�nry Trnmship Tavng tlistria (riry, rown, rowrtshiP)
n ber Legal d ption I5 �he property in Question:
6- r�f � l. �� � b�� � Real property ❑ AnnuaM asse:sed rtabile home (IC 6f.1-n
If any ponion d tne razidentlal sWCWra or Ne IaM not azceeding one (7 ) aae Nat immediatey surtauntls ihat strucL�re is use0 to produce income, descnbe the use arW portion
of Ne propefty u�(¢eE tn p�oCUce inmme.
• � • • � a • •
Caunry Trnmship Caunry Township
I hereby certify ihe above statements are We, cortect and complete. Signatu o/ ai t �
AdAress (numEer� s!' out�Ofe, anE ZlPcdg) ` .I ,� � � � � �
�a5 S w � ivv:�
� . �� . �
'" ' ii ..
land not eiceeding 1(one) acre immediatety .��.f� s, g�'��- "`"t�`-ch.s'?=
surrountlin residential im rove+nents. ��� :..`_� �^�_„�-�i`s' ��:�::s�:�
_. � ....,.4;.. �.a .
Other land (z) �i��':�-��:j��i�,�` �
Total land pine 1 plus line 1) (3)
'St" -.t r�� '.i'z" s F*'i'-tit.
Dwellin9 (4) 4..'-.'Nti � 'j �SF."6.�,t'�'�'t ,�F'.t.Y3`
Residen4al improvements or Mnualty -
OsscssetlMObilelManufacturetlHome '`-fr�-,,,�i r;-w�7� � ��%�''�`=
GaraBe �5) �r;.''..s.-_,`"--°;.;:n'.:".�:��wti.i3�3'c::�`y
�_ �.-,r-,W�....._. .,
��; ."� A'FFY )i.S..
Olherimpmvemenb (6) _ °.�,,;.�-v��...$,z
Total Improvements (Itne e Nroagh line 6) (7)
Total value (llne 3 plla Iine � (B)
I hereby certify the above is [rue, correct, Sig�wre of nssessar Data signed (month, day, yaar)
and complete.
Vairying aqion - Signature of P�dimr Date syned (rtronN, tlay, ysa�
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20 _ pay 20 _ Lesser of 60% of the assessed value of ihe homestead or 545,000 - -
NofwitASterMing eny othelprovision. Ne sum ol the deduclions prounled in IC 61.1-72 fn a moO�7e fpme Nat a 5
not a.csessed es reel propeM or to a manufaUUred hame Naf is mt essessed as real pmperty meY ra� erceed
rnehaH (12) W Ne assessed ra�ue o1 Me mobde home ormanWaclu2d honie.
Sigriawre oflvitlitw �ale signeE (rtwiHr. day, yea�
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