Homestead_Wood�
1!
1
° CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD/SUPPLEMENTAL DEDUCTION
�•�.".. Sha:e Fortn 5473 (R72 / 609j
S,��. ' Prescnbetl by the Department of Local Govemmenl Firence
INSTRUCTIONS: See raverse side for filing inshuclions.
I`l�
M YE
co
�UL 2 2 2009
I(We) ' ceAiry that I(vre�,), o�.c^cu� i��Uyu� �(oAy�ifrlb[3al
place of residence or am (are) buying the following desaibed real roperty for whirh a Homestead Pmperty Tax Sta(O�(9�duc�on is hereby daimed
under conVact on Ihe da[e this application is filed. (date of filing):
�e) own ❑ Am (are) buying under recorded conVad
Am (are) en[i0ed to occupy as a tenant-stockholder ot a cooperafive housing corparation
� Have a benefidal interest in the wst or the right to occupy the property under the terms of a qualified personal residence wst
Name of tla'imant (kgal pxne)�
!A % LJ
Sodal Sewrin/
Sotial Seartiry numbv ot daiman['s s{wusa (laz
If buying om m�vsd, Fee Simple ownefs (ame
Recordefs ofirE wl�ere mnVact is recoNed
Caunry Tc
Drivefs license / Identifnation /
o� Uaimant (WSl frve digifs) � —�.
of da'imant's spouse (lesf frve digrfs)
Parcel num6er lRa�aesrnP�on
/7 =.�0-�OO -on/�3 ri�� �bS/JJ,
If any portion of Ue resitlential swcwra w Ne la� nol exceetlirg ane (1)
of ihe OroPertY utifaeG to pmduce income. �7O _ 3_/ ^
OC o{
..�. . �
Counry iawnship
I hereby ceNfy Ne above statements are we, cortea and complete.
Address (number antl slreet. tiry, slafe.
Land
acre Immediatety
Otherlantl
Total land (line 1 plus line �
Dwelling
Residentlal improvementa or Mnualty
Assessetl Mobik I Manufactured Home Garage
Other improvements
Total improvements (llne 0 Nrough Ilne �
Total value (I/ne7 pf�s Ilne 7)
1 hereby certiy the above is true, cortect,
and complete.
Veitying action - Signawre a1lWdi�or
(�)
iz)
(3)
�4)
(5)
(6)
i�)
Tating
a immeAiatey
/ ��
(8)
SignaWre ofAUessor
Counry
Recortl numher
Paqe
proPerty in queslion: .
�j2ea1 v�operry ❑ Mnualy assessed rtwbile home (IC Si. f-
ihat swcnire is used to produce income, desmhe Ihe use and portion
20 _ pay 20 _ Lesser of 60% ot the assessed value of the homestead or 545,000
NohvithslaMing anY �herP��n. Ihe sum W Ihe deduc(ions prowded in IC &7. f-12 m a mob0e Mme Ihat is g
rwt euessed es real property a ro a menufeGUreAhome Naf a not assessed as real pmperty meY �t ermetl
ono-hatl (1l1) o/ Ne assessed vaNa o/ tha mobd � a wmanu�acturad horr�e.
Township
Da:e signed (rtronN. daY. Yea�)
Da:e si9netl (monN. OaY.
iea (rY'J(tlay �V / �