Mobile Home_Selby i
lift�'" CLAIM FOR HOMESTEAD PROPERTY TAX if III YEAR
STANDARD / SUPPLEMENTAL DEDUCTION FORM
State Form 5473(R13/12-09) Mji 132013 HC10
Prescribed by the Department of Local Government Finance .
INSTRUCTIONS:See reverse side for filing instructions. �airient17 j.
, . r _ CAT CERTIFIIONSTATEMF_NT"c- , - , - - - c ,.,
I(We) �' • -02_0 / . 5- 2L - certify that I(we)occupied as my(our)principal
place of residence or am(are)buying the following descri stir-al property for which a Homestead Property Tax Standard Deduction is hereby claimed
under contract on the date this application is filed, (date of filing). I(We):
n ❑ 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
O Am (are)the shareholder, partner or member of the entity that owns the property.
irv:.Yr a.:-. IIir-,_III3iIr-I ci‘if CL'AIMANT'S'INFORMATION _ `ii.fah'.fls`..ya-gV'*�<t�": ,;, 4 .' - „..._
Name of daimant(name) c 5-`
Social Security number of claimant's spouse(last five digits) Driver's license/Identification/Other number Issuing State
of claimant's spouse(last rive digits)
.a`z : >.. .t 4 ,- ,.r.-= art. _1=s-r - *t.>=? •CONTRACT RECORDED '..; - •f,.. - -`I
If buying on contract,Fee Simple owner's name
Recorder's office where contract is recorded Record number Page ,,�
si
. ,.4'' - PROPERTY;DESCRIPTION•�-. : � a = '=e . _• - ::-% SVI
Counq Township Taxing district(city,tow/llownship),
Gf€- 4/-�U $/-OO •li2
Parcel number Legal description Is the property in question:
tatirstirThrirneri ❑Real property Annually assessed mobile home(IC 6-1.1-7)
If any portion of the residential structur a land not exceedin one(1)acre that immediately surrounds that structurels us o produce income,describe the use and portion
of the property utilized to produce in e. , , c
®` /
*-* -_::.-, ��^�+--^. _ .._JPROPERTY OWNED$Y CLAIMANT IN-0THERTCOCNTIESt a 1 t.:: .i--� `•"-'=-
County Township County Township ,
I hereby certify the above statements are true,correct and complete. S`igrnature of claimant
Address(number and street,city state and ZIP. e) •
y S ill
ASSESSEDVALUE HOMESTEAD-+" 1reNON-RESIDENTIAL_ -
ASSESSOR_USE ONLY - _FTRUE.TA)C-.VALUEo1-AT'1 r rY`O Ilt '-. ALUE4". Pt .. ''�--- V E 4''-
Land not a reeding 1(one)acre immediately (1)
surrounding residential improvements.
Other land (2)
Total land(line I plus line 2) (3)
' Dwelling (4)
Residential improvements or Annually
Assessed Mobile I Manufactured Home Garage I(5)
Other improvements (6)
Total improvements(line 4 through line 6) ) (7) rl e1
Total value (line 3 plus line 7) � \b (8) 61\d! ii
hereby certify the above is true,correct, \ Signature f Assessor Date signed(month,day,year)
Iand complete.
Verifying action-Signature of vditor Date signed(month,day,year)
®\ ' - -. a :".,,jam-t; i -• -'STANDARD DEDUCTION ALLOWANCE"— ':.,'- .. .r..-:r. . +T-4
20 pay 20 Lesser of 60%of the assessed value of the homestead or$45,000
Notwithstanding any other provision,the sum of the deductions provided in/C 61.1-12 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(1/2)of the assessed value of the mobile home or manufactured home.
Signature of Ayditer �_. - / Date signed(month,day,year)