Mobile Home_Coomer a CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
:e FORM
STANDARD I SUPPLEMENTAL DEDUCTION
State Form 5-773(R15/5-14)
/ Prescribed by the Department of Local Government Finance '
INSTRUCTIONS:See reverse side for filing instructions.
NOTE:Telephone.Social Seaway,driver's license,state identification and federal identification numbers are confidential under IC 5-1.1-12-37. ‘ `S.
L ' < ` ' �' __CERTF�ICATIONSTATEMENT - - X,-_ •1 :3 ;, r.r---'-\3-r-•,. ') .
® I(we) I�•--•?-T iir.1'I:I��/I.g a.I).• • . certify thatl(we)occup;-•as 4y(�; r). ' ipa ,
place of esl•ence or am(are)buying th-following described real property under contra' for which a Homestea• Property Tax Standard
• Deduction is hereby claimed on the date this application is signed, (date of signature. I(We):
CI Own. ❑ Am(are)buying under recorded contract. APR I 201'
❑ 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 persona idence us
❑ Am (are)the shareholder, partner, or member of the entity that owns the property.
=r CAI ArmsiNFORMAnoN _ 4a u' .`� DITOR
Name .o ant(legal name) Telephone number of claimant '
Social number of damart Bast five dgls) Driver's rcense/Iden•W5ca'on l Other number Issuing State
Na o• imanfss (legal name)
Social
..
Recorder's o5ce where corSac is recorded Record number Page
ab- 4a0 - IPSO Ito -00
y - :�;' - = l? r' orii-PROEERTY DESCRIPTION:-•:ti---"hC =-i3. a.-;!'.inA1.cf, 'nf 4_aese
Couny Township � Taring district(city,town,tomMy)
Parcel number Legal description Is the property in cuestiorr:
❑Real property +/A wally assessed mobile borne(IC 6-1.1-7)
If any portion of the residential structure or the land not exceeding one(1)acre that immediately surrounds that sttuoure is used to produce income,describe the use and portion
S the property unlined to produce income.
® a0pa at 3 ' : la N
I Sate.Coney,and Township Is claimant vacati g a homestead?
QQQ ❑ Yes ❑ No
I hereby certify the above statements are true,correct,and complete. 4' j ` _
Address of cont act(number and street city stae,and ZIP code) Ad•-of vacated tK.aestead,if any(n re •scree•/my.slate,and ZIPcode)
acv e
ASSESSOR USE ONLY I ASSESSED VALUE I HOMESTEAD VALUE I NONRESIDENTIAL
Land not exceeding one(1)acre immediately (1)
surrounding residential improvement
Other land (2)
Total land(line 1 plus line 2) (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) (7)
Total value (line 3 plus line 7) (8)
I hereby certify the above is true,correct, Signature of assessor (� Date signed(month,day,year)
and complete. -\
garaging action-Signature of ud'.tor \/ \ Date signed aware day,year)
Jet -- �
.-';x. -.K>a.- 3`-C45"" 'e _"-gip=:STANDARDDEDUC11ONALLOWANCE �] .,rt rig ?A "-: '41.
•- 1 :Si
20 pay 20 Lesser of 60%of the assessed value of the homestead or$45,000
'�
® Nohvithstanding 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 toe manufactured home that is not assessed as real property may APR 7 2015
not exceed one-h (12)of the assessed value 4(the mobilee(ome or manufactured home.
Sg ^,-rt
rae CAW::u •
�+/ I,.�` Date ygnea( 'h
DISTRIBUTION: Original-Cou yAUd.tor,FdeSampedCopy-Taxpa~'yen('_/•,►AV GIBSON/f/a��COUNTY AUDITOR