Homestead_Embree (2) !!--'*, CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
blpSTANDARD/SUPPLEMENTAL DEDUCTION FORM
State Form 5473 IRIS!1-20) HC10
t ..90. 3
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-•,,,„..--t ., 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.
.... —
'CERTIFICATION STATEMENT
I(We) --,S%\\ 2:-- w\b,ree._ INik. . certify that I(we)occupied as my(our)principal
place of residence or am(are)buying 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, 3V 44 1 3 (date of signature). I(We):
eivn. 0 Am(are)buying under recorded contract.
Am (are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation.
0 Have a beneficial interest in the trust or the right to occupy the property under:the terms of a qualified personal residence trust.
0 Am (are)the shareholder, partner, or member of the entity that owns the property.
Recorder's office where contract is recorded Record number Page
. . - — PROPERTY DESCRIPTION - — - ..._
County Township 0 R. Taxing district(city,town,tovmsh.ip)
( t\eftleW\ ,00011110
.roll IF---
It --.41t '• C''''S Vt‘•\I-en
Parcel number Legal description Is the property in question:`ft,
aG-o' -0 9- 0100- 000, In( -C91-7 , • actfal property D Annually assessed mobile home(IC 6-7.1-7)
If any portion of the residential structure or the land not exceeding one(1)acre that immediately surrounds that structure is used to produce income,describe the use and portion (3
of the property utilized to produce income
C.3
"71
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State,County.and Township Is.s',ant vacating a homestead? )
Ilikl Yes [f"No
c'.....)i:-F—Slic,igiilfeIllr Illgilli: . , .
I hereby certify the above statements are true,correct,and complete. '-`''''..4- ''
rs.3
Address of contact(number and street,city.state,and ZIP code) Address scaled homestead,if any(number and street,city,state.and ZIP code) I
1 i 54 P e: *)'0 4‘./ . •
IOLA ei 0 ,3r 3°( E 400 A) Pak9 141 -(3 n-ti -4)(4 6 --C-
ASSESSOR USE ONLY ASSESSEP VALUE I HOMESTEAD VALUE NON-RESIDENTIAL 0
VALUE
Land not exceeding one(1)acre immediately
surrounding residential improvements to G
Other land (2)
• ' I'
'LED
Total land(line 1 plus line 2) (3)
Residential improvements or Dwelling (4)annually assessed mobile/ 0
manufactured home Garage (5) ,-,',..:.AP .R.0 4:208.Other improvements (6)Total improvements improvements(line 4 through line 6) (T) .
a,
Total value (line 3 plus line 7) (8) GIB.ON COUNTY AUDITOR
- C.V1
I hereby certify the above is true,correct, Signature of Assessor Date signed(month,day year) .
1
and complete.
Verifying action-Signature&Auditor Date signed(month,day year)
1
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. 1-.)
Signature of Auditor Date signed(month,day year)
Atle, 1X)6dOkt4'\. 7 ,"' 1-1 11 it 3
DISTRIBUTION;Original-County Auditor,File-Stamped Copy-Taxpayer
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