Homestead_Hollingsworth e-'^o, CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
• J STANDARD/SUPPLEMENTAL DEDUCTION FORM
.- State Form 5473(Rig/1-23) HC10
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Prescribed by the Department of Local Government Finance
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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) }',/� I i~ r certify that I(we)occupied as my(our)principal place of
residence or am(are) uym the following des n d real property Jhder contract for which a Homestead Property Tax Standard Deduction is hereby claimed on the
at is application is Wed, (date of signature).1(We):
Own. El Am(are)buying under recorded contract.
m(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 t . v
❑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 rGJ�� Township Y 0) Taxing District(city,town,township)
Parcel Numb Legal Description the perty in question'
eal Property 0 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 immediately sun ds at structure is used to produce income,describe the use and portion
of the property utilized to produce income.
2.4. 1 _ O 1.
0I --000, n l --00Q......S
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State,County,and Township
Is Claimant Vacating es[ead.
El Yes o
i Signature of Claimant
I hereby certify the above statements are true,correct,and complete. Wesley l+0 1 , �5W(//t
Address of Contact(num.i and street,city,state,and ZIP code)` Address of Vacated Homestead,if a y'(nmber aim street ci , tate,and ZIP code)
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ASSESSOR USE ONLY I ASSESSED VALUE HOMESTEAD VALUE NON-RESIDENTIAL VALUE
Land Not Exceeding One(1)Acre Immediately (1)
Surrounding Residential Improvement
Other Land (2)
Total Land(line 1 plus line 2) (3)
Residential Improvements or Dwelling (4)
Annually Assessed Mobile/ •
Manufactured Home Garage (6) yyy (15IN
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Other Improvements (6) �w\
`��j ly
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Total Improvements(Line 4 through Line 6) (7) ' Q�
Total Value(Line 3 plus Line 7) (8) a!, ,,y0\
Signature of Assessor O ate Signed(date,month.year)
I hereby certify the above is true,correct,and complete. ON‘-'
Ventying Action-Signature of Auditor \.3 Date Signed(date,month,year)
STANDARD DEDUCTION ALLOWANCE
20 Pay 20 Lesser of 60%of the assessed value of the homestead or S48,000.
Notwithstanding any other povision,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 ' :ssed as real property may not
exceed one-half(1/2)of the assessed value of the mobile home or home.
Signature of Auditor dts.
` Date S red(m h, a y ar) 7N^2,I?
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DISTRIBUTION: Onginal-County Auditor,File-Stamped Copy-Taxpay:
Wage 1 of 2