Mobile Home_Hall c '�. CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
t _,- STANDARD / SUPPLEMENTAL DEDUCTION FORM
?i, State Form 5473(R13/12-09) HC10
..4i.- ! Prescribed by the Department of Local Government Finance --
INSTRUCTIONS:See reverse side for filing instructions.
• -
CERTIFICATION.STATEMENT a
I(We) I (2-I a i
I certify that I(we)occuple• as my • � 'cipal
place of residence ram(are)buying the following described real property for which a Homestead Property Tax Standard pgdyctirjs hereby 0 claimed
under ct on the date this application is filed, (date of filing). I(We): I tLtfil iI x
Own ❑ Am(are)buying under recorded contract n
El Am (are) entitled to occupy as a tenant-stockholder of a cooperative housing corporation -/// r A�
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a qualified pers l Ns aattttHbbTY AUDITOR
❑ Am (are) the shareholder, partner or member of the entity that owns the property.
�., . CLAIMANTS,INFORMATION` r__, _-_,.litairibiaiii
Name ofdaimant(legal name) .
Social Security num of daima94(last five digits) Driver's license/Identification/Other number /,l Issuing State-- n
tiI' 4403 of claimant(last five digits)
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O �!,�r� •••"kkksss"'��I �„
Name of claimant's spouse(legal name)
q1-1 WO
Social Security number of claimant's spouse(last five digits)I Driver's license/Identification/Other number Issuing State
of claimant's spouse(last five digits)
......- ;- 7 _ ..-:_ s_ . - := CONTRACTI,RECORDED =--t. _..�,.,_ . _.e_=.a.•+rx: :.Z z°1(ira
If buying on contract,Fee Simple owner's name
Recorder's office where contract is recorded Record number Page
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I- - = - OP ERTY—oSC—R iTriciN-__ .., - 3- .— - - _ : - :..a
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County Township Taxing district(city,town,township)
2WI number Legal descdpl� F/ Is the pro perty in question:
)6-Li a -OS 050 -00 f y I,S�1 ❑Real property ❑ Annually assessed mobile home 6-1.1-7)
If any portion of the residential structure or the land not exceeding one(1)a that immediately surrounds that structure is used to produce income,describe the use and portion
of the property utilized to produce income.
- - A1;- r _rPROPERTf OWED BCAMAIN OTHRCOUNTIES _ •_ , , ,., ,--"„_ „ _ _
County
Township County Township .
I hereby certify the above statements are true,correct and complete.
S•irt
��•f�'(/1 of claimant��” --
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Address("umber.•d s,:-L dry,state,an•ZIP code) ?� h
_ a A . ` � v s. - ' - .r i t l ��f-0 n IN si-/ 7 07 0
ASSESSORVSE ONLY { t rTRR -VALUE IrA99ESSEDVALUEI HOMESTEAD r� :NON-RESIDENTIAL
- _ - .,,r.,c _ r_qtr=-•s^r.ie••vv a• —� ar_ ifia 100%.OFsTTV. ..,:.sSVALUE.it I - VALUE
Land not exceeding 1(one)acre immediately
surrounding residential improvements. 0)
Other land (2)
Total land(line 1 plus line 2) (3)
Residential improvements or Annually Dwelling (4)
Assessed Mobile I Manufactured Home Garage (5)
Other improvements (� (6)
Total improvements(line 4 through line 6) lc (7)
®,I value (line 3 plus line 7) \ `\\`, (8)
hereby certify the above is true,correct, Signature of Assessor Date signed(month,day,year)
I and complete.
Verifying action-Signature of Auditor Date signed(month,day,year)
-. _ s- �_;,,�.• __ . -STANDARD;DEDUCTION'ALLOWANCE __y �•�_ S' ?_° - __r. , a
I 20 pay 20 Lesser of 60%of the assessed value of the homestead or$45,000 -
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