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"'" CLAIM FOR HOMESTEAD PROPERTY TAX
'� STANDARD / SUPPLEMENTAL DEDUCTION
S� v State Po�m Sa73 (R72 /609)
�O � PrescnbeO by Ne Departmerrt of Loml GovemmeM Frerc» '
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INSTRUCTiONS: See reverse side fw �rg instrtictions. "
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I(we) �%w `'�n C certity that 1(we) occupied as my (our) prindpal
place of residence or am ( r buying the following described real pmperty for which a Homestead perty Tax Standard Dedudion is hereby daimed
`,u�,n�der mnVaG on lhe date s applicalion is filed, (data of �ling):
'p�J I(V✓e) own ❑ Am (are) buying under recorded contracl
�❑ Am (are) enlilled to occupy as a tenant-stockholder of a cooperative housing corporelion
� Have a benefldal interest in the wst or the right m occupy the pmperty under ihe tertns of a qualified personal residence Wst
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Name ot (legal neme) � .
Sodal Sequiry nnibu of ' (
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Sodal Setwiry number of tlaimanCS spousa (lasl five O'grts) Drivefs license / IdenGfxation / Other number Issuing State
W daimairt's spouse (la9 five d5ds)
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11 buyin8 om m�trad, Fea Simple ownels name
Remrdefs a1GCe where mntrad is remNed Remrd numbrl ' Page
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� Township T � ' . bwn. fnwnship
Parcel num6er Lege� d Is Ne pmperty ci question:
lt1 �� v�venY ❑�nua0y assessed rtrodle home (IC &7.7-n
M anY Po� � Ne �esWential swcwre or Ne Ia�W rwt exceeduig me (1) aue that Inunedately su s ihat strucWra is used to yndure Lx�ne. desaibe Ne use anO poRion
of ine propery uaT¢ed m pfoduce
aG - � /3 - �� 000. ��a. -��
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Counry . 7ownship ' Caunry Trnmship
I hereby certiy the above stetemenLS are we, cortect and complete. Sig�cu o1 daimant �
Pddress (num6er anC atreet, tlfy, afate, and LPOOda)
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Iand not ezceeding 1(one) acre immediatety `�?j�v'��-�'�"`�=�n� '`i=
surroundin reslCential im rovements. �» a-T--�'-%s?�'-.+�-!�z-� ����— �u�
�� �e.y�-. ,i�`�. .
Other lantl (2) :'�;2�'y,;> � �
7oGl land (Iine 1 plus line 3) (3)
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Residential ImprovemenLS or Mnually ��ling (4) �,�y� �,.� �3, ,R�, h�"�"„
Assessed MoCiie / Manufactured Hame Ga2 e ��°{�'����� �T
9 �5) . eF=�'-r�'r`�a�.�'^�'�'.�' '�x�
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Olher Im rovemems (6) '�;n:'�i��'��
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Total Improvementa (llne d through 17ne � (7)
Tofai value (1ine7 plls Ilne 7) (B)
. I hereby certity the above is hue, cortect, Sig�aNra atASSesmr ' Date slg�ed (monfh, dey. yeer)
and wmplet¢. .
Vedying actim - 55reWre of �tor Date si9ned (mmlh. daY. YTa�)
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20 _ pay 20 _ Lesser of 60 h of the assessed value of Ihe homestead or $45,W0
Nart�ilhslantlug anY �herprovislon, Ne sum W Ihe deductiona pro�idetl in IC fi1.1-72 ta e rtrobde home Nst is $
not essassed as real property w fo a manufaUUiatl hortie Naf a rrof asseued as �eal poperty may rrot axceed . _ -_
ore�hanlf2) d Lre essessed value oI Ne rtpb8e home wrtanuYac(urea home.
Sgnature M�wr Date signed (monlh, daY Y�
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