Homestead_Rogers a'"•rtxh� CLAIM FOR HOMESTEAD PROPERTY TAX I YEAR
a _=1 STANDARD I SUPPLEMENTAL DEDUCTION FORM
a! HC1 O
State Form 5473(R18/1-20)
•'' 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) IA I A • / '..4--... ' •- A"a.Q_ certify that I(we)occupied as my(our)principal
place of residence or am(are)buying t,(following•-scrd-d real property under contract for which a Homestead Property Tax Standard
Deductio " by claimed on the date this application is signed, (date of signature). I(We):
Own. ❑ 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.
D Am (are)the shareholder, partner, or member of the entity that owns the property.
_-
If buying on contract.Fee Simple owner's name
N 2
Recorders office where contract is recorded Record number Page
N h
PROPERTY DESCRIPTION N
I County Township Taxing district(city town.township)
Parcel number Legal description Is the props n L) 7
Z6- ' ,02 ''-9Sz �ZLO sal property ❑Annually assessed mobile home(/C 6-I.t-7C.4 LyJ L
/B- 3-� ^o. ^pr . _
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 F�+.1 �
of the property utilized to produce income V.
Q
C
PROPERTY OWNED ELSEWHERE BY CLAIMANT
Is claimant vacating a homestead,
Slate.County.and Township
❑ Yes ❑ No
I hereby certify the above statements are true,correct,and complete. �� ,
stead.it a umber and street.city state.and ZIP code)
Address of contact(number and street.city.stale,and ZIP code
,CalA/ — Ailsc./C t Af J d
ASSESSOR USE ONLY I ASSESSED VALUE I HOMESTEAD VALUE NON-RESIDENTIAL
VALUE
surround ng resident al((m)pro ementsdiately (1)
Other land (2)
Total land(line 1 plus line 2) (3)Residential improvements or I Dwelling (4)
annually assessed mobile/ Garage (5)
• manufactured home -
Other improvements (6)
Total improvements(line 4 through line 6) (7) - -- -
Total value (line 3 plus line 7) (8)Signature of Assessor Date signed(month,day yeah
I hereby certify the above Is true,correct,
_ and complete. Date signed(month,day year,
ing action Auditor ,^, // &- � I a-/2-Z Z -
.1 Ltd F-en�'
;AN JARD DEDUCTION ALLOWANCE
20 pay 20 Lesser of 60%of the assessed value of the homestead or$45,000.
he
ions provided in IC 6-1 1-12 to a mobile home
thatis not assessed as realp property or to a manrovision,the sum of ufactured�uredthome S
any other 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. Date signed(month,-7 ^d7ay,year)�/
Si a� /"/ ////�! I Z' 1 G. 4Lr
DISTRIBUTION:Original-County Auditor,File-Stamped Copy-Taxpayer
• Page 1 of 2
•
.
`.`��"°
Verifying acibn - Signature of Autlimr Date signed
STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _
Lesser of 1/2 Homestead S
Valuation or 52,000
SignaNre of Auditw Date signed