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"'' CLAIM FOR HOMESTEAD PROPERTY TAX
z� ._.. ? STANDARD / SUPPLEMENTAL DEDUCTION
State Porm 5473 (R12 / 6-09)
�O � Presaihad by the Department of Loml Govemment Friance
INSTRUCTIONS: See reverse side for �ng instruclions.
�''l OR YEAR
�H--{ HC7
g
JUN 2 2 [uw
• •
�(We) �' certiry tr�(� �up' as my (our) prindpal
place of residen or am (are) 6uying the following bed real property for whi a Homestead Pro� Mlf�dad�h��ereby daimed
under mnvaU on the date lhis applintion is filed, (dafe o/filing):
� I(We) own ❑ Am (are) buying under recorded conVact
❑ Am (are) entitled to occupy as a tenant-stockholder o( a cooperative housing corporation
� Have a beneficial interest in ihe Ws� or Ihe right to occupy the property under the tertns of a qualified personal residence Wst
�• � •
Name o( tlaimani (kgal neme)
f�4 rno °� �l4 � R �Q �-t
Sotial Seartity nurtibei d qa'u�ant (lasf fi�e digis) Drivefs license I IdentifinUOn / ONer num� Issuirg State Q/
/ / iY Q' / of tlaimant (last frve digifsJ 4 7� ^ �M �
CD (O d O �O � �///v
Name of a' ni's spouse (legal na )
G c 4 rt�
Sacial SerLriry
• ••� �
11 buying om m�tract Fee Simple wmeYS reme
Remrdefs otfice where contract is recorded Remrd number Page
..�. . � . �
�nry Township Tamg distrid (city, f , townshiP)
Pam.el number Legal desaiP� Is the pioperty in qu�fian:
' � Real pmperty � MnuaOy assessed modte home (IC 61. f-n
�If arry portirn ot Ne revCential swcwra or Ne IaM rot exreetlirg ane (1) arre lhat irtvneEiately wrtountls �hal swcW re is used to produm Inmme, desrribe �he use aM porGOn
of Ne propeity utJ¢ed te pmduce i�ome.
� a �-� 4-ig- 303 -cn / � I �O -aa �
-.. . .: . .
Counry Trnmship Caunry Township
I hereby certiy the above statemenis are we, correct and complete. Siqriaw daimam �
�
Addrew (number aM sheef. ury, state, ard LP cod ) I
o� , S� 76
,. , , . ., . ,
„.. �
Land not ezceeding 1(one) acre Immediately � t^i,��., q'�y. �"< � T'.,`�'�.�
surtaundin residentialim rovements. � � .�1=..,.�"�* *?3i''�{ C��;s:s3
Olher land (2) t � €�`^�F�'��:
'�,�.a
Total land (line f O�us line 2) (3)
Dwelling (4) .*.`��r ��: r '�3��°`r
s' Y��4,�5_�s �`i` y-s��u�
ResidenUallmprovementsorMnualty -�y �'� } � _
0.asessed Mobile I Manufactured Home Garege (5) �t 3� ��:� '�"����?`h.i_dc--"(',-
�:':• �= '�'i�5:y�=`;-'S:
Otherimprovemenb (C) '' S_':�n�',%t?.�..
Tatal improvementa (llna 4 throug� line � (7)
Total vatue (Ilne 3 plls line � (8)
I hereby certify the ahove is true, cortec[, �9^a�� of Assessor Da:e signee (monM. tley, yxar)
and complete.
VaiNM�9 action - 55rewre of PLdtw Date signeE (rtronfh. tlay. l�A
� . - � � � • •
20 pay 20 _ Lesser af 60% of Ne assessed value o( ihe homes[ead or $45,000
NMviNSlanC4g anyWher pmvisbn, fhe sum ollhe detluc�ims provided in IC E7.1-f P to a rtwb�ie lame Nat is g
not essessetl as real property w to a menu/ertured hwne fhat a rpt essessed as real property may rml erceetl - -
one�haX ry!1) W the assessed valua ot Ne moDde homa w manNactwed horr�e. �
SignaWre Wlvitlitw Date signed (monN, Oay, yea�