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"'" CLAIM FOR HOMESTEAD PROPERTY TAX
� _ , STANDARD / SUPPLEMENTAL DEDUCTION
3, State Form 5773 (R72 / 609)
�O � Pfascribed by ihe DepaMmnl of Loml Govemmenl Frefue
INSTRUCPONS: See raverse side /or �rg instr�ctions.
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1 �� i' � 'I�
APR 14 2011
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�iWe) ce�$IB����4NP(�.� IU�Prindpal
place ot residence or a are) buying the folbwing desuibed real property for which a e d Pmperty 7ax Standard Deduction is hereby daimed
under mnVad on Ihe date this appliption is filed, (date ol fili
❑ I(We) own ❑ Am (are) buying under recorded conVaG
❑ Am (are) entltled to otcupy as a[enanFStockholder of a coope2tive housing corporetion
� Have a beneficial interest in ihe Wst or the right to occupy the properry under [he tertns of a qualified personal residence Wst
•• • .
Na qa"unant (leyal nam
Soaal Se�vrily Orrvefs license / Identifiplion Issucip State
� � of Uaimant (lasf �rve dip8s) �
N of dam�ani's spouse (legal neme)
Sodal Seamry
�+— 1�1
• ••� �
tl Mrying on cun4act, Fee Slmple mmefs �wna
Reoo�defs otfice where wnt+aU is remtleE � Remrd numbei Page '
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Caunry Tamshi0 T' tlistrict (uN. , townshiP)
Parcel number l desoiP� 7`L Is Ne P�Perryin Question:
� � Real yoperry ❑ AnnuaDy assessed mod'le home (IC &1.1-7)
, tt any portbn of Ue residentlal swcWre or Ne lantl nol e ing one (1) aae that immetliatety surtou�Ms ihat strucWre is usetl to pmCUce incame, EesU@e �he use and portion
ot Ne pmperry u0T¢ed to proCUCe mcorta.
a�-I�-13 -4od_ 000.8Y3-o � ` .
-.• . �: . .
Coumy Towns�iP �M' TwrtaNp
I hereby certify Ne above sfatements are we, correcl and complete. Signatu o�-/t aimani /� �
l.
Mdress,(n�rand �t.cal:s7efeti�LPCOde) O!- ✓ �l ilG.i'�
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Land not exceeding 7(one) acre immediatety ��a"=' �,'i s'� �o ,�.��'�'''�
surraundin resitlential im rovemen�. ' ��) � � -�i"��'��=�k`=@z�>n <Ka �:�:?dk's�'>i+�sN:�*�
Other land (2) ������''4;?�a
7otal lantl (line 1 plus line 1) (3)
y 4
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Dwellin9 (4) ae�-�x"�i'*'���:4rv:cr�.st.?,',�-,.aY-s-
Residential improvemenb or Mnually
0.ssessed Mobik / ManuFactured Home Gara e �-r�-.1,, � 5 ��+'�''t. -�ni��'tY.
9 �5) ;:�SSfS„'1..,.'�.`_, 3�'�w�..�S`F�E,'9. ±,.t:
:�E�rf, _ t,�±-.
Other improveme� � (8) :�S},,$: --;s;;?���'2'.
7atal improvemenb (Ilna e NrougAline � (7)
Total vatue (lirre 3 p/us line 7) (8)
I hereby certify ihe above is true, cortect, Sg"ab'� °���55Of ��'� (��' �y ��
and complete.
� Verty��s aa� -. sg�m�e m a,a�ca o-a� s�anea (monur, aer. r�
�.-.. . . .
20 pay 20 _ Lesser of 60% ot the assessed value of lhe homestead or $45,000
NWwiMSfarWirg any Nherprovision, Na wmW tha deductqns prowded in IC 6f.1-12 ro a mobde home Nat fs $
rrot essessed as reel properry w lo a menulaUUred home Nat 6 rrot essessed as real property mey rwf e+teed
onefiatl(7/2) W flre es5esseC ve/ue W fhe mob8e Aome dinanularluretl fartie.
SkJnature o(AUtlitw Date siBnetl (rtwaN. EaY. Y��
C.T.