Homestead_Schwartzlose (6) CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
�; STANDARD/SUPPLEMENTAL DEDUCTIONJ FORM
`rP HCIO
` ��. Form State 5473(R77/1-16)
Presaibed by the Department of Loral Government Finance
INSTRUCTIONS:See reverse side forfihing instrucffons.
NOTE:Telephone,Social Security,driver's license,state identification and federal identification numbers are confidential under IC 6-1.1-12-37.
CERTIFICATION STATEMENT
I(We) Ck_r Llp Q r OSe_ certify that I(we)occupied as my(our)principal
place of residence or e)buying the following described real property under contract for which a Homestead Property Tax Standard
Deduction� is hereby claimed on the date this application is signed, (date of signature). I(We):
E Own. El 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
❑ Am(are)the shareholder, partner,or member of the entity that owns the property
name , r w`-`O� '
Recorder's office where contract is recorded Record number 05'''*Page
PROPERTY DESCRIPTION 1177
County Township Taxing district(city,town,township) •
Parcel number Legal description Is the pnata_O in question:
property 0 Annually assessed mobile borne(1C 6-1.1-7)
if any portion of the residential structure or the land not exceeding one(1)acre that immediately surrounds that structure is used to produce income,describe the use and portion
of the property utilized to produce income.
a � o"L Q — i + .00a .gLOg of -
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State,County,and Township Is claimant vacatin omestead?
0 Yes o
' Signatureo claimant
I hereby certify the above statements are true,correct,and complete. 4
Address of contact(numberand sheet,city,state,and ZIP code) . Address of vacated homestead,if any(numbera ,and ZIP code)
ASSESSOR USE ONLY I ASSESSED VALUE 1 HOMESTEAD VALUE NON-RESIDENTIAL
VALUE
Land not exceeding one(1)acre immediately (1) y,
surrounding residential improvements ._..r_.._
Other land (2)
Total land(line I plus line 2) (3)
i
Residential improvements or IAve0ing (4) _.,:`;_....,,_., <..,...,.-,,..:.. .'.,_ :`
annually assessed mobile!
i t
manufactured home age (5) ,
Other improvements (6) . '
Total improvements(line 4 through line 6) (7)
Total value(line 3 plus line 7) (8)
I hereby certify the above is true,correct, Signature of Assessor Date signed(month,day,year)
and complete.
Verifying action-Signature of Auditor Date signed(month,day,year)
STANDARD DEDUCTION ALLOWANCE
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 1C 6-1.1-12 fo 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(1/2)of the a essed value of the mobile home or manufactured home.
Sig of Auditor Date sig ed(month,day,year)
- �� I 19
-.)
DISTRIBUTION:Original-CountyAuditor,File-Stamped Copy-Taxpayer
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