Homestead-Blacklock CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
;14 STANDARD/SUPPLEMENTAL DEDUCTION FORM ^�
\ Sq?" State Form 5473(R17/1-16) HCI0 2. V
Prescribed by the Department of Local Government Finance
INSTRUCTIONS:See reverse side for filing instructions.
NO7E Telephone,Social Security,driver's license,state identification and federalidentrlcation numbers am confidential under IC 6-1.1-12-37.
T CERTIFICATION STATEMENT
I(We) Alf� ►� Q L • certify that I(we)occupied as my(our)principal
place of residence or am are)buyint e 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):
Own. 0 Am(are)buying under recorded contract
m(are)entitled to occupy as a tenant stockholder of a cooperative housing corporation_
A _
❑ 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 contract,Fee Simple owner's name
Recorder's office where contract is recorded Record number Page
PROPERTY DESCRIPTION
County A \ Township Taxing district idly,town,township)
()J)
Parcel number Legal description Is a roperty in question:
Real property ❑AnnuallyA.aased mobile home(IC 6-1.1-7)
If any portion of the residential structure or the land not exceeding one(1)acre that immediately surro ds th structure is used to produce income,describe the use and portion
of the property utilized to produce income.
6 -A3�3 g-^,100 .-CPO .uk3 —0Ql
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State,County,and Township - Is claimant vacating a homestead?
❑ Yes ❑ o •
Sign- re of claimant /
I hereby certify the above statements are true,correct and complete. ®�I ' ./ ) r I I t
Address of contact(numberand aeeet,dig state.end ZIP code) ddress of --,..v d homestead,if any(number and street,city,state,and ZIP code)
4034 s .9-30 e F 1( Dr).- L1.-1-.6 9
ASSESSOR USE ONLY ASSESSED VALUE f HOMESTEAD VALUE NON-RESIDENTIAL •
Land not exceeding one(1)acre Immediately (�) Z
surrounding residential improvements
Other land (2) s.r
Total land(line 1 plus line 2) (3) ` i
Residential improvements or Dwelling (4) F I,� ry r
annually assessed mobile!
manufactured home Garage (5) lr^
Other improvements (6) e"" gog�
Total improvements(line 4 through line 6) (7) I
' 4 !
Total value(line 3 piss line 7) (6) 1 r i,rtiT,,r
I hereby certify the above is true,correct, signature ofAssessorG I B S O N COUNTY AU U ITO ate 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 oche 'si•/e sum of the deductions provided in IC 6-1.1-12 to a mobile home $
that is not assessed as re. • .•:./ or to a manufactured home that is not assessed as real property may
not exceed one-ha6(1/2)• l-- sassed value of the mobile home or manufactured home.
Signature of Auditor ,. Date signed( nth,da year)
D
DISTRIBUTION:Original-CountyAuddor,File-Stamped Copy-Taxpayer
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