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* CLAIM FOR HOMESTEAD PROPERTY TAX h YEAR
��' �, STANDARD ! SUPPLEMENTAL DEDUCTION FORM
., Stale Form 5473(R20/12-24 L HC10 al°
.�. )
'•�• Prescribed by the Department of Local Government Finance '
INSTRUCTIONS See reverse side for filing instructions
NOTE: Telephone, Social Security, drivers license, state identification and federal identification numbers are confidential under IC 6-1.1-12-37.
CERTIFICATION STATEMENT
I (We) i( C) d.. !—'O.ti\e ] certify that I (we)occupied as my(Our)principal place of -
residence or am(are)bu followir> escri d real ro rty‘under contract for which a Homestead Property Tax Standard Deduction is hereby claimed on the
date application is signed, — .(date of signature), I(We)
n. —: 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.
Recorders Office Where Contract is Recorded Record Number Page
PROPERTY DESCRIPTION
County Township Taxing Dist _i.jpwnownahrp)
C-6 1 r�
Parcel Number Legal Description Is the pr rty in question.
Real Property 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 surrounds that structure is used to produce income.descrbe the use and portion
of the property utilized to produce income.
oz-.) (0 _ t —\ — k 0 -a._ 00p `-1 gam.. 0CLA
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State.County.and Township Is Claimant Vacating a Homestead'?
YYes __1 Nc
Signature of ant
I hereby certify the above statements are true, correct, and complete. Y i.,,-- ."_--------
Address of Contact(nug er.and street.city, sta and ZIP code) Address of Vacated Homestead.if any(number and street city state and ZIP code)
‘I . 111 e_.A.St 0. SCA %\Y 6‘.....0... - . 0 , k jit.....i .
i
ASSESSOR USE ONLY ASSESSED VALUE HOMESTEAD VALUE NON-RESIDENTIAL VALUE LCI� V(S
Land Not Exceeding One(1)Acre Immediately (1) `�n ""
Surrounding Residential Improvement
Other Land (2) Pit
.,
Total Land (line 1 plus line 2) (3)
Residential Improvements or Dwelling (4) 4:6
Annually Assessed Mobile i - - -
Manufactured Home Garage (5) s1_ (Sep !
Other Improvements (6) S
Total Improvements (Line 4 through Line 6) (7) 4O(73•
Total Value (Line 3 plus Line 7) (8) 10/1v - - ,0 -
Signature of Assessor CO& • ate Signed (date. month. year)'
I hereby certify the above is true, correct,and complete. 7.)." ,
//,, "•, date,month,year)
Action-Signature of Auditor v�? •• � y )
O9
STANDARD DEDUCTION ALLOWANCE
20 Pay 20 Lesser of 60°- of the assessed value of the homestead or S48.000
I $
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,gf Auditor Date S g (month, day. year)
\.)...... 10.3.
C'&
DISTRIB TION! Onginal-County Audtor File-Stamped Copy - Taxpayer
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