Homestead_Wolf (3) 4 CLAIM FOR HOMESTEAD PROPERTY TAX FORM
a;' 4. STANDARD/SUPPLEMENTAL DEDUCTION HC'10
State Form 5473(R113/1-20)
Mil
� � 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 IC 6-1.1-12-37. L7
CERTIFICATION STATEMENT
I(We) „if udl ' certify that I(we)occupied y(our)pn'c�a -40
place of residence or am(are)buying the fol owing described real property under contract for which a Homestead r Tax Standar '
Deduction is hereby claimed on the date this application is signed, (date of sign' We: O<2<2
BSI Own. ❑ Am(are)buying under recorded contract. NCO
((( ❑ Am (are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation. C�Nj-;_ _
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a qualified personal residence trust,,,5
❑ Am(are)the shareholder, partner, or member of the entity that owns the property. TOR
Recorder's office where contract is recorded Record number Page
PROPERTY DESCRIPTION
Co(�/w To ip Taxing district(city,town,township)
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'Palle umber ' gal description Is t�he(yoperty in question:
Jy 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 inynediateiy surrounds that structure is used to produce income,describe the use and portion
of the property utilized to produce income. •/�!l!/) 0
��l9—,3S/4ro -oat
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State,County.and Township Is claimant vacating a homestead?
❑ Yes ❑ No
Signature of claimant
I hereby certify the above statements are true,correct,and complete ,/'¢-r7 / , 1
/
Address of contact(number and street.City.state.and ZIP code) !Address of vacated homestead.if any(number and treet city state.and ZIP code)
Ag4A5 e, -- ?- -
ASSESSOR USE ONLY 'I ' ASSESSED VALUE HOMESTEAD VALUE 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) I -_
Other improvements (6) - --
Total improvements(line 4 through line 6) (7)
Total value (line 3 plus line 7) (6)
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)
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STANDARD DEDUCTION ALLOWANCE
20 pay 20 Lesser of 60 the assessed value of the homestead or$45,000.
Notwithstanding any other provision,the sum of t e deductions provided in lC 6-1.1-12 to a mobile home $
that is not assessed as real property or to a man factured home that is not assessed as real property may
not exceed one-half(1/2)of the assessed value f the mobil ome or manufactured home.
Signatu `W-nd''2or///{J � Date signed(month,day,year)
DIS�ON:Original di File-Stamped COPY-Taxpayer ��]/Z/4�
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