Homestead_Cousert (2) CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
_ 1 STANDARD I SUPPLEMENTAL DEDUCTION FORM
State Form 5473(R17 I I-16) HC10
4-'" Presentee'by the Department of Local Government Finance
INSTRUCTIONS:See reverse side for Kling instructions
NOTE:Telephone,Social Secunly,dnvets license,state idenbhcaton and federal idenbfcation numbers are confidential under IC 6-1.1-12-37.
p, _ , -CERTIFICATION STATEMENT _ F,_ _ -
I(We) Duane usual certify that I(we)occupi- l e T prince I
place of residence or am(are)buying the following described real property under contract for which a Homestead. d ape ;Ta(Stae
Deduction is hereby claimed on the date this application is signed, (date of signature). I ^e:
• Own. ❑ Am(are)buying under recorded contract. JULI
❑ Am(are) entitled to occupy as a tenant-stockholder of a cooperative housing corporation. 0 5 2019
❑ Have a beneficial interest in the trust or the right to occupy the property under the tens of a qualified personal residence trust.
❑ Am(are) the shareholder, partner, or member of the entity that owns the property.
Name of claimant Nepal name) iekphone C $ OR
Diane Cousert 1 ( )
Name of claimant's spouse(legal name)
Social Seruny number of daeuants spouse(fast lye dyes) Lrners license l Idea/peahen/Other number of claimants spouse(last five digits) Issuing Sate
(App(cable only d applicant's spouse dues not have a soda/secunty number)
If buyig on contra&Fee Simple owners name » _
Recorders office Mere contort is recorded Record number Page
_. - ✓._. PROPERTY DESCRIPTION a - r.. <
County Tosnslvp Taxing OMNI(cry.foss township)
Gibson Barton Barton
Parcel number Legal desrnpon Is me property in question:0 Real properly ❑ Annually asse ssed,mbae home(i 61.1-7)
If and portion of the residential structure or the land not esteeming one(1)acre that immedatey surrounds that structure is used to produce income.describe Lie use and portion
26-20 —ace-300 — cnZ. t -oo\
___ . - ,�'.PROPERTY OWNEDELSEWHERERYCLAIMAtfl _ _
State,County,and Tovmshp :. Is claimant vacating a homestead?,
0 Yes j No
Signature of claimant
I hereby certify the above statements are true,correct,and complete. Cats}.Cc.-..`t-
Adress of contact(number and sheet,sty state,and ZIP code) Address of vacated homestead,E any(number and street,Hy,state.and ZIP code)
5133 S 675 E, Francisco, IN 47649
ASSESSOR USE ONLY ity , 'I" 'ASSESSED VALUE .I. - HOMESTEAD VALUE a7 I ANON-RESIDENTIAL
VALUE
Land not exceeding one(1)acre immediately I11 -
surrounding residential improvements - -
Other land (2) -
Total land(line 1 plus line 2) (3)
Residential improvements or Dwelling (4) _
annually assessed mobile
manufactured home Garage (5) .
Other improvements (6) •
t
Total improvements(line 4 through line 6) (7)
Total value (line 3 plus line 7) (8) I
I hereby certify the above is true,correct. Signature of MUM, Date signed(month.day.fear)
and complete.
VerGying action-Signature of wd:or Date signed(mwrh,day,year)
t3120k14 4/-i r.11
STANDARD DEDUCTION ALLOWANCE .'e •.
20 pay 20 Lesser of 60%of the assessed value of the homestead or S45,000.
Notwithstanding any other provision,the sum of the deductions provided in IC 6-1.1-12:o a mobile home
that is not assessed as real property or to a manufactured home that is not assessed as real properly may
not exceed one-half(Ira)of the assessed value of the mobile home or manufactured home.
Signature of Auditor Date signed(month,day fear)
a ,� 07/05/19
DISTRIBUTION:Orgnal-County Audenr.FleSUmped Copy-Taxpayer
Page I oft