Homestead_Hathaway f` ;, CLAIM FOR HOMESTEAD PROPERTY TAX + YEAR
G�'& STANDARD/SUPPLEMENTAL DEDUCTION FORM
� State Form 5473(R15/5-14) HC10
�• Prescribed by the Dept-Mimi of local Gover..meru Finance
INSTRUCTIONS:See reverse side for filing instructions.
NOTE:Telephone,Social Security,drivers license,state identification and federal identification numbers are confidential under IC 61.1-12-37.
_-.-^_ - - _ - -� •CERTIFICATION STATEMENT2t. - -'-
I(We) .70 "' CWT al A_ ,_ 7 certify that I( 3�ed s my( r Pri I;
place of residence or am(are)buying the foil. "41•escribed real property unde e•ntract for which a H .'�`:�((l'P .
Deduction is hereby dawned on the date this application is signed, to of119r�
❑ Own. ❑ Arn(are)buying under recorded contract 2016
El Am(are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation. JUL 3 Il
❑ Have a beneficial interest in the trust or the right 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.
• 1-.:al
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"'-"..
it toying on contact.Fee Simple owners name
Remrdets c5ce where contract is recorded Record number Page
J"1- lice`{
Lamy T- I• _ : r 2 . "POPERTY:DESCRIPTON- rr -- :.3-st -.g__ l
Township
Taring dsthd(oby,toast township)
Parcel nt_.ber Legal desolation Is the property in question
❑Real property ❑ Armuaiy assessed mobie home(IC 61.1-7)
e any pommn of the residential strt tie or the land not exceeS-g one(1)acre that inmedately strands that stifltn is used to produce incense.describe the use and portion
of the property cubed to pmdpm income.
‘g 06-33 -300 - DOD 3 -sae)
.Canty.and Tip Is of rant vacatng a homestead?
❑ Yes ❑ Nc
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Signature of claimant
reby certify the above statements are tru , rrect,and complete. - •
Address Cr canto Orate'and abee(•.,nab,and ZIP(rde) Address of vaaded homestead,d any(number and street r$:dab.and ZIP coda)
• ASSESSOR USE ONLY I ASSESSED VALUE ( HOMESTEAD VALUE I NON-RESIDENTIAL
Land not exceeding one(1)acre immediately I(1) _ ';-�-'-T'i� _; _
surrounding residential improvements - __.•_
Other land (2) _c- ;�� ..
Total land(line 1 plus line 2) (3) _ - - -
Residential Improvements or Dwelling (4)
Annually Assessed Mobile l
Manufactured Home Garage (5) `.. -W ' , ,tfi 3•
Other improvements (6) _-;
Total improvements(line 4 through line 6) I(7)
Total value (line 3 plus line 7) I(B)
hereby certify the above is true,correct, serrature ofA••..•nr Dare signed(month.day.year)
I and complete.
Verifying anion-Signature of AUddor Date signed(month,day year)
z---a-{Wi ili-S'> '_, „ STANDARD DEDUCTIONAII:OWANGE S?S" 's4�- ..j
20 pay 20 I escar of 60%of the assessed value of the homestead or 545,000
Notwithstanding any other provision,the sum of the deductions provided in/C6-7.1-72 to a mobile home S
that is not assessed as real papery or to a manufactured home that is not assessed as real property may
not exceed one-h (112)oft the assessed value mode home or manufactured home.e.- /1 s/^/�� n+d/1, I/,,
Signature olNd4wM� Ili �W O� / ( 1 3 / &
DISTRIBUTION:Origial-County Aucktor,FeeS`amped Copy-Taxpayer
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