Mobile Home_Beadles rr., CLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR
i STANDARD/SUPPLEMENTAL DEDUCTION
114 Sate Form 5473(R15/5-14) HOTO
Preaoibed by the Department of Local Goverment Finance
INSTRUCTIONS:See reverse side for filing instructions. I ,f
NOTE:Telephone,Social Sewnly,driver's license,state identification and federal identification numbers am confdenti nder 6-'I - - tt1111 CC
• I(We) • certify that I(we)occ6� as2n4(o2ryltrtdpal
place of residence or am(are)buying the following described real property under contract for which a Homestead Property Tax Standard
Deduction is hereby claimed on the date this application is siined, (date of nature). I(we)'
' ism• n. ❑ Mn(are)buying under recorded contract. j((�19(IYM
• Am (are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation. GIBBON COUNT
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a qua I led personal residence trust
❑ Am (are)the shareholder, partner, or member of the entity that owns the property.
Name o'tla m(legal
nname) /
Social Security number of claimants spouse(last the dgds) Driver's license/Ident5cafon/Other number Issuing State
of claimants spouse(lag five dgds)
r+cs,5- .,s_, r ' � .: .. .FPONTRACT,RECORDEP _= f..°_ q" :..1.4r-
If buying on contract,Fee Simple owner's name
Recorders office where contrail is recorded I Record number Page
.i' ^c _- -- 'c PROPERTY.DESCRIPiiON.. --.7.. .,. .f"`_.' . .... a.sc ice f
County I Township (*/���e I Taxing dish t(dly,town,township)
Parcel number Legal dessmnpticn • I pmperf c Inn'/I, � Annuah assessed mobile home(/C 6J.In
If any portion of the resgental&melee or the land not teezxed ng one(1)acre that'immediately surrounds that structure is used to produce 4mme,descnbe he use and portion
• of he property uliraed to produce Vienne.
- = e_ _.
02 6 — 4/027- 05%0_ -o
PROPERTY OWNED ELSEWHERE BY CLAIMANT
state,county.and T.sip Is claimant vacating a homestead?
❑ Yes ❑ No
Isgnrnre of e .
I hereby certify the above statements are true,correct,and complete.
• ..- of contaa(number a••^greet mty.gate.- •ZIPcode) • - -fed hvnea'.ead.d any(number and•wet.oty,siege,and ZIP code)
• r ( 2 1/
/ �Jr-.t J t \ -I
ASSESSOR USE CY! ASSESSED VALUE I HOMESTEAD VALUE I NON-RESIDENTIAL
VALUE
Land not exceeding one(I)acre immediately (I)
surrounding residential improvements
Other land (2)
Total land(line 1 plus line T) (3) I
Residential improvements or Dwelling (4)
Annually Assessed Mobile I ,
Manufactured Home Garage (5)
Other Improvements (6)
Total improvements(line 4 through line 6) (1)
Total value (line 3 plus line 7) I(8)
I hereby certify the above is true,correct
Signature of Assessor Data signed(r.WA day,year)
and complete. r�
Vadyug a an-S nature of 1� \t ( Doe signed(Morih,day.year)
I I
t . , = -..* x= `ri. _:STANDARD DEDJCTION ALLOWANCE:,' ..'7-7-A:::::;47-1-76:-;., `r- -Lrt. s4�
20 pay 20 Lesser of 60%of the assessed',Sue of the homestead or 545,000
•
Notwithstanding any other provision,the sum of the deductions provided in IC 6-1.1-12 to a mobile home $
that is not assessed as real property or to a manufactured home that is not assessed as real property may
not exceed one-half(112)of the assessed value of the mobile home or manufactured home.
Sg:a ^udd V f1/4- /:4va '
Dare s✓,.ne0(mom,day.Yee
DISTRIBUTION: Otigtal-CountyAud o4ReSampedCopy-Taxpayer 9 C�[�/T7/
