Mobile Home_Tate i _'�ia CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
�' . STANDARD/SUPPLEMENTAL DEDUCTION FORM
�y� State Form 5473(R18 f 1-20) HC14 -*
w�'`�,`�„4 . Prescribed by the Department of Local Government Finance (X'�t'• (��
INSTRUCTIONS:See reverse side for filing instructions. V — U�Ct — & ///���
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NOTE:Telephone,Social Security,driver's license,state identification and federal identification numbers are confidential under IC 6-1.1-12-37. t /
CERTIFI-CATIONSTATEMENT
I(\Ne) W'r ' , Qir_ certify that I(we)occupied as my(our)principal
place of residence or am(akbbuying 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, 7^ 1--1***2-i , (date of signature). I(We):
L7 town. ❑ 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.
''`o: 7- . 741:,t ;?3717 . ' y'„ `CL'ATMANj:S„INFO ?ATION T .:21:'c+` 14X 'r y.-v"'f -
Name of claimant(legs/name) Telephone number of claimant
*1*--'0 e. (81 , tetaiS*"..CA l
Social Secur y number o imam(last five digits) Driver's license/Identification/Other number of claimant(last five digits) Issuing State •
-` ' ^ • (Applicable only if applicarrl does not have a social security number.) - r •
Nam,.- lairnent's spouse(legal name) ((-- (�.S^J (\`,�\
Social Security number of claimant's spouse(last live digits) Driver's license/Identification 1 Other number of claimant's spouse(fast five digits) Issuing State i
(Applicable only if applicants spouse does not have a social security number.)
•
' ,CONTRACT RECORDED . - - ` ' - -
If buying on contract,Fee Simple owner's name
Recorders office where contract is recorded Record number Page
PROPERTY DESCRIPTION
County Township Taxing district(city.town,township)
Parcel number Legal description Is the property in question:
D Real property nnuatly assessed mobile home(IC 6.1.f-7)
If any portion of the residential structure or the land not exceeding one(1)acre that immediately surrounds that structure is used to educe income,describe the use and portion
of the property utilized to produce income
• 010-or -s-1- o 6•- o00 .t ta g
PROPERTY OWNED ELSEWHERE BY CLAIMANT State,County.and Township Is claimant vacating a homestead? (pi( /
- ❑ Yes E4
Signature of claimant —
I hereby certify the above statements are true,correct,and complete. ,tee(i,. or k j_a..Z,
"
Address of contact(number and street.city.state,and ZIP code) Address of e ernes a i a (number andstreet,city,state,and ZIP code)
1110
ASSESSOR USE ONLY I ASSESSED VALUE HOMESTEAD VALUE NON-RESIDENTIAL
VALUE
Land not exceeding one(1)acre immediately {1)
surrounding residential improvements S ®
Otherland (2) - i' -.LEIS
Total land(line 1 plus line 2) (3)
Residential improvements or Dwelling (4)
annually assessed mobile/ -.FEB tJ 'l..
"
manufactured home Garage (5) -t
•
Other improvements (6) , //,
Total improvements(line 4 through line 6) (7) ; zi av
Total value (line 3 plus line 7) (8) GIBBON COUNTY AUDITOR
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)
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 IC 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 value of the mobile home or manufactured home.
`Signature of AuditorDate signed(month.day,year)
0.�Q a - 2-- -.DIS\r,_o_i...
ION:Original-County Auditor,File-Stamped Copy-Taxpayer
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