Homestead_Adams (6) ` "CLAIM F.OR<HOMESTEAD,PROPERTYSAX _
I- . ,, STANDARD/SUPPLEMENTAL DEDUCTION_ FORM Y
Shto Fmn54T3(R17/1-16) HCIO
bed byte die Depariirem of Lama Caaa Firenze
anze -
INSTRUCTIONS:See inverse side forfiing instructions.
NOTE'Telephone,Social Secungy,dnvers kcense,stab•fdenf6eation and federal idr 3cation numbees are 6:45dential uiMer C bf.1-12-37. .
. /-off'•• • I CERTIFICATION STATEMENT';''
I(We) - - Oa,. ... . _ . ._ that I(we)oauped as p prat 11
place of residence or: (are)buying the ftilorling described real property under contract for which a Homestead Pro Ta St4.dard
• - Deduction is hereby darned_on the date thig appficatiori is signs: - • - (data of signature). I(VJe)t ""�•
❑ Ovm. p1 Am(are)buing uridef recorded contact - AUG 3 0 18
❑ Am (are)entitled to occupy as a tenant`stockholder of a cooperative housing corporation._
❑ Have a beneficial irlterest in.the trust or the right to ocaipy the,property under the terns eta qualified personal residence trust
❑ Am(are)the shareholder, partner,or member of the entity that owns the property. '•s n
F e r '" :'..+> s 5';2 CLAIMANT INFO-d•TION'e r' ^relt.7 y =-•� /rl� ....y-• - '�
.1 F- >0.sie. l ' rtvd .a-.._,c lc`�-.
Nix sit claimant ra�m)q (/��, / a- ,
Semi SeanYr.ter ddamarfs spouse(last five cts)) Dova's tense l I n/Oaw cumber of chive's spo`e(Iasi fire ctgts) Isssrg Sae
I(Mi ble orgy✓eper/anes spouse does not haven anal seculynurnberJ
c _- "' r 2:ef .- .-ti-. CONTRACTLRECORDEDV4.
If teyug co cJornans,Fee Sti ie cremes names / •"'" . ,
e 5 ', - 1/tEmtdCd i �dA�4 -
R soce S contract's Reyb roster Page
ab a. a
a
:f:*ATr:' - �y'PROPERTY DESCRIPTION .r�_ -:•7-r,:t- v�-.}b.-s"- {
.•`•`sic
Panael number Legal desoir-on Is the piGgert HIgw_SEWS "" •'•`• �..
•
. . _. _ d/f..property -❑Annualy asessed mobae home yce-/.1-N'
It any pootei of the residereul smiths"or the land not exceedng one(1)ace that irmedatly- .. .de that stymie a used to prod.=modne,descnbe the use and radon
of do properly uileed b produce income_
_ .
• ; 3- 5 '`3 - off: /_99 oa
is `� _ .., it '}art twee y i.- ROPERTY,OWNED ECSEYVHERE BY CalMAN1,"c_€ 1;:- ,7 y' h:.,�-.1:::-j
State.Gouty.and Tomhsstipp- _• Is claimant vadating a homestead? ~
,a❑'Yes h❑ No . .
_. . r tru.h ..
I hereby certifyare the above statements ue.correct,and complete. 1/rr'®jJ
Atldess d car2tl(umdirani street Obt nee and Z/Pm1)' - - binestiad 3 ininurrber arsfshM,obi,Sae aniZiPwce)
' O. 60.. rr 7 /-r.;veto.- 7f- 'r7670,
1 (ASSESSOR USE ONLY T _7 ASSESSED VALLUEry 1 HOMESTEAD VALUE r ' Y� NON-RESIDENPAL''t
Land not exceeding one(1)acre Immediately K 1 .i e, ...._ 1-; r_ -a;
surround-mg residential improvements - ( ) . - . .. L- :k _t< '- s .-7--;y
2 -_$-;�
Omer lantl. .: __ i� T. . . . -:r, •
Total land(line i p/ris fine 2) • ^' (j) _ _ •s+= ..
Residential improvements or D'welgng (4) a?Y y-r' '*AJ Y K Y_.
annually assessed mobile I . . -.; r ;
manufactured home- Garage
Other im rovements oli 6 - + "#
. .. _.._ . _ - ._ .
Total improvements(line4 through line b) (7) . -
Total value(line 3 Plrs fine 7) • (B) . .
I hereby certify theaboveisttiue,correct, SeareofAssesscr . ' Daa;esrad(mayl;day,Yeaar)_' -
and complete.
Venting�n.- -Signaaureofludtr _ s Data.ngned(=nth my,yea)
.s >1"-y 7"47.4 -4.— I :.t::..STANDARD DEDUCTION ALLOWANCE Stet.7.T.a,.. I S ''-r.'c("•, x s - ^-ci'
20 Ray 20_ ,Lesserof60%of the assessedvdue of the homestead or$45.000.• -„ . -
NohwMhstanding any oThefprovision,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-had(f17)of the assessed vakre of the mobile home ormanufachm.N home.
Sigh�seedAutlb • _.._ a Date (?1IRlh,r'ay.K)
•
DISTRIBUTION:atonal-CanyAudtu•FYe3anpe?Cipy-TapaYer- r ,
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