Homestead_Ellerbruck CLAIM FOR HOMESTEAD PROPERTY TAX YEAR ,
�� a [ FORM
°�i }� STANDARD/SUPPLEMENTAL DEDUCTION ��p�
s .L State Form 5473(R)8/1-20) -. 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 identification numbers are confidential under/C 6-1.1-12-37.
CERTIFICATION STATEMENT
I(We) •)✓ 1 • certify that I(we)occupied as my(our)principal
place of residence or--• -re)buying the following described real prope y)undgr contrrRct for which a Homestead Property Tax Standard
Deduction is hereby claimed on the date this application is signed, - (, (Icy ,L[ (date of signature). I(We):
Own. ❑ Am(are)buying under recorded contras.
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.
1
Social Security number of claimant's spouse(last five digits) Driver's license/Identification/Other number of claimant's spouse(last five digits) Issuing State
(Applicable only if applicant's spouse does not have a social security number.)
CONTRACT RECORDED
If buying on contract.Fee Simple owners 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, perry in question:
fi/I•.C]t(\Real property ❑ Annually assessed mobile home(IC 6-f.1-7)
It any portion of the residential structure or the land not exceeding one(1)acre that immediately surrou cis that structure is used to produce income,describe the use and portion
of the property utilized to produce income
2c -2,o - o2- e-ke --000. 2S-10 CDOE .
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State.County.and Township s elaat�nt vacating a homestead?
'17I Yes ❑ No
S ature of claimant
� I hereby certify the above statements are true,correct,and complete. �(
Q�' Address of contact(number and street.city,state.and ZIP code) ,• \_ /\`I Address of vacated homestead.if any(number and street.city,state.a d ZIP code)
Cm
1 NON- NTIAL
ASSESSOR USE ONLY ASSESSED VALUE HOMESTEAD VALUE iVALUE `'-')
CD Land not exceeding one(1)acre immediately (1) 7 .,.#�y.i y -T(j b
surroundin.residential im•rovements
W) Other land (2) ys - ,( i .f,
Q S Total land(line 1 plus line 2) (3) if
l Residential improvements or Dwelling (4) ILL
annually assessed mobile I g022es�rexF ice"
N) I manufactured home Garage (5) • A Q 1 . L ,
Y whit' y,. d r
Q Other improvements (6) '+,.,; ��-�*.-*' =1
( Total Improvements(line 4 through line 6) (7) I i
`sr'J_ Y AVp1TOR
Total value(line 3 plus line 7) (8) qq 01.1 •
1 hereby certify the above le true,correct, Signature rettaMN C 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 other provision,the sum of the deductions provided in/C 6-1.1-12 to a mobile home $
that is not assessed as real property or to a manufactured home that is not assessed as real property may
not exceed one-half(1/2)of the assessed of the mobile home or manufactured home.
Date V( or mfi (I
)
Signature of• e .r \QQJJ
01111