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STANDARD SUPPLEENA DEDUCTION FOR
q'-4 - HC•10� State Fort 5473(R17/116)
"--� Prescribed
by the Departrrlerttof Local Government Finance
INSTRUCTIONS:See reverse side for filing instructions. _
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) • % P3 I V Ma • certify that I(we)occupied as my(our)principal
place of residence or am(are)buyin•the following described real property under contract for which a Homestead Property Tax Standard
P ••,«*on is hereby claimed on the date this application is signed, (date of signature). I(We):
J Own. ❑ Am(are)buying under recorded contract.
❑ -m(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.
Social Security number of claimants spouse(last five digits) Driver's license I Identification/Other number of claimants spouse(last five digita) Issuing State
(Applicable only if applicant's spouse does not have a social security number.)
CONTRACT RECORDED
If buying on contract 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 legal description Is i; •'arty in question:
TA.---property 0 Annuailyassessed mobile home(/C 6-1.1-7)
If any portion of the residential structure or the land not exceeding one(1)acre that immediately surro..s -.'v cture is used to produce income,describe the use and portion
of the property utilized to produce income.
A 6
12 -11^ 03 --003 , ' u• -
•
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State,County,and Township is claimant v g a homestead?
❑ Yes No '
yHai /�'/
I hereby certify the above statements are true,correct,and complete. - C� �
Address of contact(numberand sheet city,state,and ZIP code) •dd--of vacated esteed,if try(nu and street,city, -= a • code)
_ I • mil, `4t. . . �h
ASSESSOII USv ONLY i ASSESSED VALUE HOMESTEAD VALUE NON-RESIDENTIAL
Land not exceedi'•..-' e(, a•'� iately (1) ' zt
surrounding real•'t - •• •cements
Other land t (2) 4 x ``
Total land(line!plus line 4NPKy®110
i
Residential improvements or Owe n (4)
annually assessed mobile 1 P `QR
manufactured home k
Other improvements `6rsQN CO�� (6)
Total improvements((hie 4 through line 6) (7)
Total value(line 3 plus line 7) (B)
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 othe sron/ e sum of the deductions provided in IC 6-1.1-12 to a mobile home $
that is not assessed as re- • •,e •or to a manufactured home that is not assessed as real property may
not exceed one-haff(112)o •-a -ssed valu- •bile home o • --r- :red home. •
Signature ofAuditor Dale signe ,day, i
DISTRIBUTION:Original-County Auditor,File-Stamped Copy-Taxpayer ,
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