Homestead_Kolb -lc, CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
. ., STANDARD/SUPPLEMENTAL DEDUCTION FORM -20��
P.
• Sun Fain 5473(R17/1-16) HOJD
Prescribed by ere Department d taW Government Anne
INSTRUCTIONS:See reverse side forting instructions
NOTE Telephone,Soda)Seanft miner's icense•slate icefllcation and federal identbeafron numbers are confidential under IC 6-1.1-12-37.
I(We) It T. O 1_ s certify that 1(we)occupied as my(our)principal
place of residence or am(are)buying the following described real property under contract for which a Homestead Property Tax Standard
Deduction is hereby claimed an the date this application is signed, (date of signature). I(We):
*PNR ❑ Am(are)burying under recaded ive housing
�����]J jj)tnn(are)entitled to oaupy as a tenant-stocktwtder of a cooperative housing corporation-
❑ Have a beneficial interest in the Mat 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.
- CLAIMANT'S INFORMATION - - . . - -
Name of clamant papal name)
/\
Soar Seamy camber atdaiaa[s space(bathe d'�) Earner's base/ ._A-- it. is/ t (dal 6%e dgts) isdng Sate
(Amimda aryl.....T IM!I.. . a .,I_ _ meter)
CONTRI,L.TRECORDED „.'. - _
C head anoxia-am Fes S6Ml ier'snme 2p19
APR 2 2
Reard&s ram Woe cram is recorded ---- -ninon Page
u
li
_SR111ie.Coay - ... . +. Toaneh ... (8....!s(r�} i•_... ..
Pawl tegtl desaylm • - dace PrNeiy in Waseca
0 Reel rgneiy 0 Anaualy assessed noble Sam(IC 61.1-])
If may adman d the msuaFa•Owen or[tat lad nd eatee±ig an(1)acre that immediately smasds Cat structaeis used d ponce inmum•describe The use and proem
et an gingery tarred to prole femme
�� . 1Z- 0S -2� —� 001 . 5e -C2s .
.i.s- ,. PROPERTY OWNED ELSE:YHEREEY CCAI6IA NT- - -{.,` ..
Ste.Casty,and Township Is claimant vacating a homestead?
❑ Yes ❑ No •
Sombre et '
I hereby oestify the above statements are true,correct, /11(',�i e and complete.- / 7�am(yw/�e�/� /..�i" ,s�
Address doace cit.(number santcit.state.and 2/Pmse) --•.. I Norther r red.ld/-sae,an(Z�cope C�-T`rK
LI
-ASSESSOR U.SE ONLY - _ , =.ASSESSED_VALUE _-..._' c HOMESTEAD VALUE ' NON RESIDENTIAL v C t rs \ `' 1D�
Land not exceeding one(1)acre immediately 1 R ��`J
sanoendi g residential enyrovements th - .S icry` :. .+<�
Other land (2) - faZ.: : .zx::'
Total land(line I plus line 2) (3)
r a 'nay `r -lzf
Residential improvements or DweNng (4)
annually assessed mobile I .t
manufactured home Garage (5) f.y -„
-C
Other improvements (6) _ 1,._.. .-.. ..- --1 72
Total improvements(line 4 through line 6) Ca)
Total value (lint 3 pas line 7) (0)
I hereby certify the above is due,correct, Signature of ssessdr Date dyad Watt d y Year)
and complete.
Vetyig action-Signature of Auttor Date steed(naval day.Year)
20 pay 20 Lesser of 60%of the assessed value of the homestead or S45.000.
NotweJnsfandl g any other provision,the sum of the deductions provided in IC 6-1.1-12 to a mobile hear* $that is not assessed as real property or to a manufactured borne Nat is not assessed as real property may
not erased one-hat(f/gof the assessed yaks of the mobile home or home.
Slmmse dructtor Oats signed(car*day,yeas)
clic`(—wA ,.-s C1ro 1-l•72 . 19 _
WSrWBUTION:Original-CartyAudtcr,Re-Slanped ropy-Taxpayer
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