Homestead_Brittingham (6) CLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR
STANDARD/SUPPLEMENTAL DEDUCTION
State Goon 5473(R15/514) HC10
�
` Prescribed by the Department of Local Goverment Finance
INSTRUCTIONS:See reverse side for firing instrucions.
NOTE:Telephone,Soria/Security,driver's license,state identification and federal identification numbers am confidential under IC 6-1.1-12-37.
r.--_,.: ,•� :CERTIFICATION STATEMENT ^ _ , 57. „-
I(we) . -/�I72j/NIPI yVI_ L. certify that I(we)occupied as my(our)principal
place of residence or a titre)buying 4-following described real p !erty under contract for which a Homestead Property Tax Standard
Deduction is hereby dawned on the date this application is signed, (date of signature). I(We):
❑ Own. ❑ Arn(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 qualified personal residence trust .
❑ Am (are)the shareholder, partner, or member of the entity that owns the property.
_ .
d buying on contract Simple°:ner's name • NOV 2/ 2016
/
i , -ago
mill
's:orta-er-`'4... An'_ Sa :6=°.--wr_ei i PROPERTY;DESCRIP-TION_ T I�]I7;.Y8]'If4�Q181Z 1LQ iro';rf win
County Township Tatrg crania:fey roan,foenshy)
Parcel number Legal desaiaico Is the property in question:
❑Real property ❑Annually assessed mobile home(IC 6-1.1-7)
If any por+on of the residertal A'C a or the land not exceeding we(1)ace❖fat im ed'ataFy surrounds that structure is used to produce income.describe the use arc portion
of the property ouTaed to produce income.
G .- -a1-1M - Coo . 0SO-01ti
State,Ca1:fy.and Township Is claimant vac:Ming a homestead?
❑ Yes ❑ No
Si of der
I hereby certify the above statements are true,correct,and complete. i\�QA"6
--of meat(number and meet au,,Nate,and ZIP code) vacated fa nezead,f any(nu and street au,,Nab,and LP code)'
V° • 3 o 40./14-tAd r b . 4 (e
ASSESSOR USE ONLY ... ASSESSED VALUE I HOMESTEAD VALUEv :I.
-.NON-RESIDENTIAL
VALUE
Land not exceeding one(1)acre Immediately
surrounding residential Improvements I CO - '-----. -.
Other land (2) _ .__— ' R'
Total land(line f plus line 2) (3) _ I - _-__
Residential improvements or Dwelling I(4) :f`:-"-'f.._.- _Vt s
Annually Assessed Mobile I
Manufactured Home Garage
I(5) • I
Other improvements 1(6)
Total improvements(line I through line 6) (7)
Total value (line 3 phis line 7) I(8)
I hereby certify the above Is true,correct, Signature ofP«ao Date signed(month,day,year)
and complete.
Vefyig action-Synaaae of Pudtor Date signed(mm:h,that year)
g-=aa +y;a''�tiSTANDARO DEDUCTION'ALLOWANCEtaT zff �_` }TS
20 pay 20 Lesser of 60%of the assessed vaue of the homestead or$45,000
Notwithstanding any other provision,the sum of the deductions provided in IC 6-1.1-12 to a mobile home S
that is not a ssed as man property or to a anufadured home that is not assessed as real property may
not exceed o all(12)of the assessed v e of the mobile home or manufactured horns.
Signature of or - Date red dal.7a
DISTRIBUTION:Original-Carty A oor,Fie-Stamped Copy-Tapayer
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