Homestead_Conner , .-
1'... .........., CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
STANDARD/SUPPLEMENTAL DEDUCTION FORM
" HCIO LkJ -l
S1YS Form 54/9(21T/1-tb]
Raaiibee Or coo Department of lad Government Franca
INSTRUCTIONS:See reverse&de for Ong instructions.
NOTE Telephone,Social Seamy,driver's license,state iden55ra5pn and lederallden2lcarvan numbers ate coadenffal under IC 6-1.1-12-37.
CERTIFICATION STATEMENT . .
I(We) )VC( ` en •ineA. certify that I(we)ocaipied as my(our)principal
place of -.'.once or am(are)buying the following dessatbed real prrperty under contract for which a Homestead Properly Tax Standard
Deduction is hereby claimed CII the date this application is signed, (date of signature). I(We):
Own ❑ Am(are)buying under recorded contract
W(,. ❑ (are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation.
0 Have a beneficial interest in the trust a the fight to ocalpy the property ands the tams of a qualified personal residence trust
❑ Am(are)the shareholder, partner,or member of the entity that owns the property.
I4a21ec(daaLL&mmq S : Qorme / •
Sa®�IYI SSeoz^
lkerYrn S Conne V
so.Semil numb,of dmnaa's lease(Iasi the dells) Driver's keens./lder4.5dian rarer narrater of tlrmats spouse(Iasi ea dots) Isurd San
ashasearOYra�aa' Sri
atoying or anima,Fee StrryM carers rave
Reraders ohm Wine cowed is recorded Read number Page
PROPERTY DESCRIPTION'�_�> - - _ - -
`aaxy \bs T Dhn,on Teeth&da(�town,
Pawl Legal aesaDIa+n ls n diesarr
Real property ❑Array assessed mobile hots(K 61.1-7)
It any par al the re*ia0al str�s or note or e lard earswg aria(1)sae din rturre6� r ly strands stun is ins to produce home Omaha the use and cation
d the properly uibed b Pods Marco.
fit — kit, 3 S �— L 00-o o2 - q&-024 .
- - PROPERTY OWNED ELSEWHERE SY CLAIMANT . .. . -. -
Sam,Corey adTow,t Is claimant vacating a homestead?
❑ Yes ❑ No
I Hereby certify the above statements are true,correct and complete.
Adder of contct(nranoaatl street dty,state.and Z.Pcock) Adders d caw toestesd.Iay(eurderad deaf,curd:Sr.de ZEcod)
7.1:40 4- wh;it.oc. L .t_._r. - a+ D rj
ASSESSOR USE ONLY =- - -` - ASSESSED VALUE'e. HONESTE D VALUE .'i' NON LIDENTIAL Lich /T
Land not mg exc oneeeding
on/)toane�wla (1) $~s':-.1 ' i.-; \surround "'1(
-Other land (2) 1,41 z�a
Total land(lion 1 plus line 2) (3) L
Residential improvements or Dwelling (4)ann i x-_'--,U• -.,-
manufactureda ran. °' Garage (5) FEB 1 ti ttib ▪ _-R
Otherrmprovio sits (7) Y 4 .
Tohl imp;a...rr..ab(line aenough line 6) (n
Total value (line 3 phis One 7) (e) GIBSOM COUNTY AUDITOR
I hereby certify the above is true,correct, 5 dAsseswr Dore signed lards dax lea)
and complete.
Vadyng actin-Signmse orAudmr Dam darned Gana day.law)
__ STANDARDDEOUCTIONALLOWANCE. _ _ - -
20_pay 20 Lesser of 60%of the assessed viue of the homestead or$45,000. .
Notaelassan irg any other provision,the slim of the deductions provided in tC 6-1.1-12 to a mobile home $
that is not assessed es real property or to a manufardrred home that is not oaten ed as real pmpeM may
rot exceed ore-hat(1I tithe assessed value d the rtrobie home or
Sigdeve drwdbr Date stem]lend,day,lead
LShe /s cs4 2 ,-� -\5
WSTWarnoN:Original-Carey Auiior,Re-Stamped Copy-Teryryer.
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