Homestead_Campbell ftCLAIM FOR HOMESTEAD PROPERTY TAX YEAR
.' , STANDARD/SUPPLEMENTAL DEDUCTION FORM
; - State Form 5473(R17/1-16) HC1O lcj
Prescribed by the Depatlmentof Local Government Finance
INSTRUCTIONS:See reverse side forfiing inshuclfons.
NOTE:Telephone,Social Security,driver's license,state identification and federalidentitication numbers are confidential under IC 6-1.1-12-37.
CERTIFICATION STATEMENT
• I(We) Cj 1 -te\ 1_l • +• V certify that I(we)occupied as my(our)principal
place of residence or am(are)b g the following d 'bed 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):
Own. ❑ Am(are)buying under recorded contract.
m(are)entitled to occupy as atenant-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.
If buying on contact,Fee Simple owner's name
Recorder's office where contract is recorded Record number Page
PROPERTY DESCRIPTION
County Township Taxing district(city,town,township)
Parcel number bagel description Is the property in question:
0 Real property 0 Annually assessed mobile home(IC 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.
26--21- - 10--Svo _ 000. 7 - 02-(1
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State,County,and Township Is claimant vacating a homestead?
❑ Yes ❑ NoSigns,•,- f 4 . „ vii\j\..
i hereby cerrtify the above statements are true,correct,and complete. ,
Address of contact(nomberend sfrsvt city,state,and ZIP code) of vacated'ome- -•,ifs mberand sheet,city -- and ZIP code)
41 ,•S 3, `t00 L-J3 it-
ASSESSOR USE ONLY i ASSESSED VALUE HOMEF rEAD VALUE NON-ALIUENTIAL
Land not exceeding one(1)acre immediately <
surrounding residential improvements (1) ... ..,
Other land (2) ` e f
Total land(line 1 plus line 2) (3)
Residential improvements or Dwelling (4) ?k
annually assessed mobile t
manufactured home Garage (5) DEC 3 . 2119`. r,
Other improvements (6)
Total improvements(line 4 through line 6) p) ,
-
-1-
J 6i
Total value(line 3plts line 7) (6) tiI@l60l4 QOUNTV Au@iTQR
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. -
Notwithstanci any; er•rovision,the sum of the deductions provided in IC 6-1.1-12 to a mobile home $
that/s not ass= sed- _:i property orto a manufactured home that is not assessed as real properly may
not exceed on- al(t'V of the assessed value of the ire home or manufactured home.
...Ail
Signature of Auditor 4/
Date std.(month,day,year)
DISTRIBUTION:Origi CoumyAudtor,File-Stamped Copy-Taxpayer •
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