Homestead_White (12) ER,rp CLAIM FOR HOMESTEAD PROPERTY TAX
d -i==.; RECEIVED FORM YEAR
STANDARD /SUPPLEMENTAL DEDUCTION
11' State Form 5473(R18/1-20) HC10 2020
• _` q
° ;�• Prescribed by the Department of Local Government Finance SEP 0 I Z019
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) Derrick L. White certify that I (we)occupied as my(our) principal
place of residence or am(are) 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, 8/17/2020 (date of signature). I (We):
IZ1 Own. ❑ 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.
)
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)
Gibson Patoka Township Patoka Township
Parcel number Legal description Is the property in question:
26-12-09-103-001.153-027 Pt W NW 9-2-10 2.0 ac II 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 surrounds that structure is used to produce income,describe the use and portion
of the property utilized to produce income.
No
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State,County,and Township Is claimant vacating a homestead?
i1 //r ❑ Yes No
Signature of claimant
I hereby certify the above statements are true, correct, and complete.
Address of contact(number and street,city,state,and ZIP code) Address of vacated homestead,if any(number and street,city,state,and ZIP code)
1527 Outer Lake Rd, Princeton, IN 47670 N/A
ASSESSOR USE ONLY ASSESSED VALUE HOMESTEADVALUE NON-RESIDENTIAL
VALUE
Land not exceeding one(1)acre immediately (1)
surrounding residential improvements
Other land (2)
Total land(line 1 plus line 2) (3)
Residential improvements or Dwelling (4)
annually assessed mobile/ -
manufactured home Garage (5)
Other improvements 6
?sup
Total improvements(line 4 through line 6) (7) c,O
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.