Mobile Home_Fields (2) CLAIM FOR HOMESTEAD PROPERTY TAX FORM
Slate
• E, v;r STANDARD/SUPPLEMENTAL DEDUCTION
Slate Fan 5423(R17/1-16) HCIO
! r� Plesoibed by the Department of Load Goverment France
INSTRUCTIONS:See reverse side for h5ng 6ebvcifots. _ ,
NOTE Telephone,Sodal Seaatr Ghent Oxnse,slate identercabon and federal ldentf6caGn numbers are oortdential under IC 6-1 I-1 -3 1 i
® CERTIFICATION STATEMENT
I(We) Q sass. a- 911EC- a certify that I(we)occupied as my(our)principal
place of residence or am(are)buying,, •I. Yg described real property under contract for which a Homestead Property ffai St®$t11118
Deduction is hereby claimed on the date this application is signed, (date of signature). ).
LN'srwn. ❑ Am(are)buying under recorded contract
❑ Am (are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation. 'eI
❑ r /.
Have a bahekiei Interest in the gust a uu/p the right to oy the property under the terms ms of a qualified personal --..I .- t-43 -
❑ Am (are)the shareholder, partner,or member of the entity that owns the property. GIBBON • Y UDITOR
. .- CLAIMANT'S IHFORtAAT10D _
7 T,1..I. . + CONTRACT RECORDED «r+"F.7';,r� - -'dr-
t buying on tareraa,Fee Simple antis tutne
Readers o5m where contract is tended Remo ratter Page
- PROPERTY DESCRIPTION-- - - -
County ^ _\ ,Township Taxing drria(ay,town,cowslip)
� I1t,a, 1 kA
Pa rQJ�tsamer Q corn
cancr*r , ''� Is ea peeper,/nei e�tt
au)—'4p !- corn 1- DO ❑Reel pmpeny ( mmCy assessed amble ltme(IC6-1.1.7)
hair carbon of the rediantaf mumre or bd m enemy one(I)toe eat matecrtaly airasldr am stmau,Is toed a cram hvma.describe the m and pmtbn
d tie property taFmi t replace intone.
dPROPERTY•OWNEOELSEWHERE,BY.CLAIMArii,. -.
Sate,Carty,and ToMa - Is claimant vacating a lwncab.al?
0 Yes ❑ No
Samar ctclaimant
I hereby ratify the above statements are true,carrel,and complete. (1
Mess of mdad(numeral street sty,slate and ZIPmdm) Addresset mead t ere S,a (number and saeet,city,YaR,and ZIPmm)
t ASSESSORUSEONLY ASSESSED VALUE- HO/AE.5TEAD VALUE NONRESIDENTIAL.
r r .. z— r '.`l. .'I :-VALUE' ...1.
Land not exceeding one(t)acme Immediately (t) ..
surrounding residential improvement"
Z )
Caber land (2)
Total land(lire 1 Plus line a (3)
nidmdal mentsmobile or Dwelling (4)
annually assessedmobile/ - •„ -
manufactured home Gauge (5)
Other Improvements (6)
Total Improvements(line 4 through line 6) (T)
Total value(line 3phs line l) (6)
I hereby certify the above is true,correct, Saxe of Assessor Data*sad Tacna ilex teak
and complete.
Volyag mean-Signature deader Data signed(roost;day,year)
20 pay 20 Lesser of %of the assessed vane of the homestead or$e5,000.
NoiWMstan0ug any other provision,the sum of the deductions provided in IC 6-1.1-12 t a mobile home S
that is not assessed as real property orb a manufactured home that is not assessed as real properly may
not exceed ore-hat(I/2)tithe assessed value tithe mobile home or mandarbnad home.
of Anti( Date signed(mord/MIX Year)
YYAvv eak(2
DISTRIBUTION:Original Casey Audit;File5tmnped Copy-Tagrayu
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