Homestead_Kirk , r, CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
STANDARD/SUPPLEMENTAL DEDUCTION FORM
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-,r�sq� State Form 5473(R17 t 1-16j HC10
Prescribed by the Department of Local Government Finance
INSTRUCTIONS:See reverse side for filing instructions.
NOTE:Telephone,Social Security,driver's license,state identification and federal MentNeation numbers am confidential under IC 6-1.1-12-37.
CERTIFICATION STATEMENT
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I(We) �� l • �t7 !tj ': certify that I(we)occupied as my(our)principal
place of residence• am(are)buying e following described real property under contract for which a Homestead Property Tax Standard
(1.1
uction is hereby claimed on the date this application is signed, (date of signature). I(We):Own. Am(are)buying under recorded contract.
Am(are)entitled to occupy as a tenant stockholder of a cooperative housing corporation.
ave 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.
CLAIMANT'S INFORMATION
Name of aim (legal name) Telephone number of claimant
C. C O-i d _ 612) 2C6 — 40 3
SodalSecud live drgib)umber of claimant(last Drivers license/Identification/Other number of claimant(last five digits) Issuing State
(Applicabe only!!applicant does not have a soda/sedrritynumber.) 1
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ame of claimant's spouse al me)
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Social number of is spouse(last rive digits) Driver's license!!Identification/Otter number of claimants spouse(fast five digits) Issuing State
. : � (Applicable•nlyH pliicant's spouse does not have a social secadty number.)
-Ifs q\vr`�/e -
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 ply,town,township) •
Parcel num� Legal description 1 e perry in question:
Real property ❑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 sumo ds structure is used to produce income,describe the use and portion
of the property utilized to produce income.
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.. l'41 ^ \jt_ 20k4- Ono . 6B4 -oe2A
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State,County,and Township Is claimant vacating a homestead?
J Jr '1 r /n' n 0 Yes No
ignat,ain lint
I hereby certify the above statements are true,correct,and complete. Y
r v r,,, -iii:,— 1r ,mberand sheet;city,state,and ZIP code) Ad = of stead,'any� tier and ,city,state,and ZlPcode) (�
GIBSON COUNTY AUDITOR 0#� S ifl ,Jr, —�`' 6 `'t 8•
ASSESSOR USE ONLY i ASSESSED VALUE HOMESTEAD VALUE NON-RESIDENTIAL
VAL
Land not exceeding one(1)acre Immediately
surrounding residential improvements (1) ,. s-
Y '
Other land (2)
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Total land(line I plus line 2) (3)
Residential improvements or Dwelling (4)
annually assessed mobile!
manufactured home Garage (5) _,-_ ., ...
Other improvements (6) .,.:s
Total improvements(line 4 through line 6) (7)
Total value(fine 3 pits 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 an • - provision,the sum of the deductions provided in IC 6-1.1-12 to a mobile home $
that is not assesse - ,I property or to a manufactured home that is not assessed as real property may
not exceed one-ha of the assessed vela e ' home or manufactured home.
Signature of Auditor 0 Date signed month, ,,year)
•
DISTRIBUTION:Original-CormtyAuddor,Fite-Stamped Copy-Taxpayer
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