Homestead_Gray (2) dCLAIM FOR HOMESTEAD PROPERTY TAX YEAR
STANDARD I SUPPLEMENTAL DEDUCTION FORM
• State Form 5473(81515-14) HCI O
Prescribed by the Department of Local Government Finance
INSTRUCTIONS:See reverse side for filing instructions -
NOTE:Telephone,Social Security,drivers license,state identification and federal identification numbers are confidential under IC 6-1.1-12-37.
• .(1j �-„1 - 'CERTIFICATION STATEMENT-1-41:-: 'L i - r, _ -
I(We) '.�-�'��1/.� - • - . certify that I(we) our "nit tl
place of resid 1 ce or am(are)buying the following t. "bed real property under contract for which a Hom Tax
Deduction is 'ereby claimed on the date this application is signed. (date /sign u I ):
❑ Own. ❑ Am(are)buying under recorded contract
❑ Am (are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation. MAD
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a qualified per lAli t .
❑ Am (are)the shareholder, partner, or member of the entity that owns the property.
<> £
a toting on contract Fee SinpIe owners name
Recorders oto where contract is recorded - Record number I Pape
r ely --rr:+�. r-.- ,= `P,ROFERTY DESCRIP-Tiiii -_ ' �L", a
Casty Township Tama Gstie(city,loon rdrish0)
Pa el nu.-iber Legal desensitize Is the pope quesim
at Property ❑ Annually assessed motile home(IC 6-1.1-7)
I any Carron of the residential strucbae or the land not exceeding one(1)acre that immediately spreads that sucture is used to produce income,describe the use and portion
of the property tabed to protium axone.
a Ia. -o3 -30b - 00o . (g3 -®a(
' _ - - - PROPERTY OWNED ELSEWHERE BY-CLAIMANT . _
'; - -
Sa"County,and Township Is claimant vacating a homestead?
. ' ❑ Yes 0 N
- -_.-
signature of daimal
I hereby certify the above statements are true,correct,and complete. (0 Q4
Address of mind(number and street cis.Sate,and IJPCCde) rated toestwG,l any(number d.curet city,sae,and ZIP code)
. , ASSESSOR USE ONLY', I ASSESSED VALUE ' I HOMESTEAD VALUE iI 'NON-RESISIDENTIAL.'
Land not exceeding one(1)acre immediately
surrounding residential Improvements (1) .[1,.
^_ s
Other land - (2)
Total land(line 1 plus tine 2) (3) - — .-
Residential Improvements or 1 Dwelling (4) I ?,_f
Annually Assessed Mobile l I
Manufactured Home Garage (5) • r .
Other improvements (6) _ --r .`
,..
Total improvements(line 4 through line 6) (7)
Total value (line 3 plus line 7) (8)
I hereby certify the above Is true,correct, Signature ofPcsecsor Data signed(moat day,year)
and complete.
Va yig aean-Signature of Audtm Date sign(ma day,yea)
5qk-titi TS-_ 4=s1'e+s-F.STANDARD DEDUCTIONALLOWANCE y
20 pay 20 Lescnr of 60%of the assessed value of the homestead or$45,000
Notxithstanding 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 properly or to a manufactured home that is not assessed as real property may
not exceed on Ir.talf(1/2)of the assessed v e of the mobile home oorrr/(manufactured home.
Stine dAU11r1 ' / `,) Date dg:ed(noYA day,yew?
MSTRIeuTfION:Orignal--•Canty4 /•'Nhorr.FieSamped Copy-Taxpayer 3 C/^`371