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Mobile Home_Harbison r- .s CLAIM FOR HOMESTEAD PROPERTY TAX YEAR STANDARD I SUPPLEMENTAL DEDUCTION FORM Sate Form 5473(R15 I5-1Q Prescribed by the Department of Local Government France INSTRUCTIONS:See reverse side for filing instructions NOTE:Telep e,Social Seca ,driver's license,state identification and federal identification numbers are confidential under IC 6-1.1-12-37. li ® 'j*r -CERT.FICATONSTATEMENT ' - {-;'i_ar '.- - 'y I(We), ' // t A—. certify that I(we)occupied as my(our)principal place of ,idence or a•$i )buying the fol owing described real property under contract for which a Homestead Property Tax Standard Deduci• is hereby clay on the date this application is signed, (date of signature). I(We): ❑ Own. ❑ Am(are)buying under recorded contract ❑ 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 personal residence trust _ ❑ Am (are)the shareholder, partner, or member of the entity that owns the property. ,,: - . 4 .: ..0 T..... a- ,siCLAIMANI'S INFOR AATION L4 -f - aaf i`;b ^'sl-x Nasa of dairnant(legal name) Tale Pita numter of 35v siL Social Sea.-fy number tieing!!gave dyts) Driver's license/Identacabon l Other number Issuing State ({yJ0 S {/y1e 4 of claimant Oast five dtss) O I I g e/ Name d claimant's spouse(legal name) VY J Social Sevu:y number of tan's spouse(Ian bye casts) Drivers license I lden:Ya'von I Other number Issuing Sax of dainant's spouse Vast fye acts) CONTRAGTRECORDED�3 - '_.• -�r'•'°;rE�-v `v.'+e 'S'? 3F ^TS( If buying on contact Fee Simple owner's name Recorders oSce where contact is recorded • Record number Page �`*` dRROPERT,,DESCRIP-TION,?7 -S+IPz- Iii-„-+`� i5:_^ Cant/ Township Tying d'Yrid(dry,town,township) Parcel=bet Legal desoip5m Is the property m queyon ❑Real property ❑Amualy assessed made bane(IC 6-1.1-7) If any paten of the residertal rwve a the land root eaue6-g ax(1)sae that i medately surrounds that=inn is used to produce irw.e,describe the use and portion ® d � you -. 9©ogm -ov • :PROPERTY-(TWNED ELSEWHERE BY.CLAIMANT Sat-_.Canny,and Township Is claimant vacating a homestead? ' ❑ Yes ❑ No Signs-are of• • n I hereby certify the above statements are true,correct,and complete. Address of m^.ad(.nmibe'and meet.city,nab,end ZIP code) ' A --t va In,.snd,if any(number and meet ray,ge9.and ZIP cede) 22‘ W. 'TR'Ill_E1t It CAW APO[I 1 �� ASSESSOR USE ONLY - : 'I - ASSESSED VALUE • .I -.HOMESTEAD VALUE r' I NON-RESIDENTIAL VALUE Land not exceeding one(1)acre Immediately surrounding residential Improvements (1) Other land (2) .-�.;i.•� ''� __� ... Total land(line I plus line 2) (3) - .. _ Residential improvements or Dwelling (4) ' -,1_-I Annually Assessed Mobile! r Manufactured Home Garage I(5) Other improvements I(6) Total improvements(line 4 through line 6) I(7) Total value (line 3 plus line 7) I(e) I hereby certify the above Is true,correct, I Signature of Assessor Date signed(m not dal'year and complete. A /� yaJt adon-Signature ofAid:tor ' 1 '.1 Date signed(mast.day,year) EK - YLg STANDARD DEDUCTION'ALLOWANCE r:Stail • 20 pay 20 Lesser of 60%of the assessed value of the homestead or S45,000 Notwithstanding any other provision,the sum of the aducions proviisedhi IC 6-1.1-12 to a mobile home S Nat is not assessed as real properly or to a mane to , home that is not assessed es real grope try may • not exceej4wL 12)of the assessed value of mobile home or manufactured home. SgrSaa // 1((y iWf DISTRIBUTIO Carry Adaa File-Sanped Copy-Tagayer