Homestead_Hurt (7) ■
nl CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
STANDARD/SUPPLEMENTAL DEDUCTION FORM
State Farm 5473(R17/1-16]
Prescribed by as DePmnma°1Om1 Goverment Finance HC10
INSTRUCTIONS.:See reverse side b,STmg h,sbuc6ons -
NOTE Telephone,Social Seaaitt enters license,state denem50n and federal idero7fraoon numbers are wnilderalW wider IC 6-1.1-1237.
CERTIFICATION STATEMENT -
I(lAt) Ja!I i i,I 4 it i / certify that I(we)occupied as my(ow)papal
place of residence or am(am)buying the following described real property wider contract krwhich a Homestead Property Tax Standard ,
Deduction is hereby datmed on the date this application is signed, (date of signature). I(We):
❑ Am(are)buying under retarded contract
Am(are) entitled to oc ipy as a tenant-stockholder of a cooperative housing corporation.
❑ Have a beneficial interest In the trust a the right to occupy the property under the terms of a quaffed personal residence trust
❑ Am(are)the shareholder, partner,or member of the entity that owns the property.
?
Roost Ter" t
Parcel neater Legal mammon Is the ache%
in a`�` GIBBON COUN R
map uty ❑Arran%assessed mC name 6. -
dam paten°to mean==stale or se land not.sseda•y at(nacre that Unmade:Sy samaras that,tonne is Gad b Produce trans&late ae as and pa3on
ads property=Teed b padm tsmm
22- /a- d10- '9007 -0o'Y. 375- 0a8'
PROPERTY"OV/NED ELSEWHERE BY,CLA'IAfANTr - _.
State,Carty,aid Tashi Is claimant vacating a homestead?
❑ Yes ❑ No
SOahsa°da'vnaa
I hereby certify the above statements am true,cared.an/d}complete. .of N /////J
° ( Gal street Mt Rae,ad ZIP cafe) 7 ar�hanedead.tom sae%t Yob, )
.S // / , • Ate 41 :de r✓
• _ ASSESSOR USE ONLY ; - 1 ASSESSED VALUE HOMESTE D VALUE::_it ._NON-RESIDENTIAL. -
VALUE
Land not exceeding one(1)acre immediately
sunundag residential lmproemarb (1) F "_ . 1 '
Other land (2) }..-.--._..-
Total land(/tire 1 plus line 2) (3)
Residential bnprnrnems w Dwelling (4) µ1 3 trt+s _pJ
annually assessed mobile I -z-acpb
manufactured home Garage (5)
Other improvement (6)
Total Improvements(line 4 through line 6) (7)
Total value (line 3 plus fine 7) (3)
ssor I hereby certify the above is true,correct Signature°tAsa Gates (morel;day,war)
and complete.
Wiysg aria-Sgnave°Mawr Data sped Month,Cal:yea)
SLNaS/IRDDEDUCTIOI- I�ALLOW7u4o —77'
20 pay 20_ Lesser°60%°the assessed vole of the homestead or$45,000.
Noteitstandr g any other provision,the sum of the deduction provided in IC 6.1.1-12 to a mobile home $
Muth not assessed as real p opedy won a manufactured home that is not assessed as real properly may
not exceed ore-hat(1/2)of the assessed va a of the®boa home or manor-awed!more.
Sidman cAaSwr Date cigriS(motet day,lea)
71,9 -u°. -7)14.?-aL 7-/6= /-7
WSTR®URON:Original-Canty AU9a,fisSanee1 Copy-Tayafer
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