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,aa CLAIM FOR HOMESTEAD PROPERTY TAX — -__-_
� ; STANDARD ! SUPPLEMENTAL DEDUCTION FORMYEAR
(1,0
! r.! State Form 5473(R20!12-24) HC10 �Z�
--'•"•- Prescribed by the Department of Local Government Financ- - ^
INSTRUCTIONS: See reverse side for filing instruction �` 1
NOTE Telephone, Social Security. driver's licen -, state identification and federal identification numbers are confidential under IC 6-1.1-12-37.
CERTIFICATION STATEMENT
9C- •(0\ Jeer I(We) l W, ! O 1 I J • 1 f S _ certify that I (we)occupied as my(our)principal place of
residence or am(ar. . • I . .. :` ri d aL�roperty under contract for which a Homestead Property Tax Standard Deduction is hereby darmed on the
/ \C1 n ate rs application is signed (date of signature). I(We)'
1 �� �` kfl
Am (are)buying under recorded contract
Q b (are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation
C 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.
CONTRACT RECORDED
If Buying on Contract,Fee Simple Owner's Name
Recorder's Office Where Contract is Recorded Record Number Page
PROPERTY DESCRIPTION
County Township Taxing District (city, town, township) 1
Parcel Num r Legal Description Is th property in question •
Real Property C Annually Assessed Motile Horne(IC 6-1.1-7)
If any portion of the residential structure or the land riot exceeding one(1)acre that immediately su un s that structure is used to produce income.describe the use and portion
of the property utilized to produce income.
2L. - L -0 0 - 2_,E ,
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PROPERTY OWNED ELSEWHERE BY CLAIMANT
Stale.County.and Township
Is Claimant Vasa Homestead
Yes No
Signatur of Claimant
I hereby certify the above statements are true, correct,and complete.
"4- k''(-ti i
Address of Contact(number and street. city state and ZIP code! Address of Vacated Homestead if any ' umber and street.city state and ZIP code)
ASSESSOR USE ONLY ASSESSED VALUE HOMESTEAD VALUE NON-RESlDENT1AL VALUE
I 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/ i
Manufactured Home Garage (5)
Plt
,..46,1)
Other Improvements (6)
Total Improvements (Line 4 through Line 6) (7) Sep !
Total Value (Line 3 plus Line 7) (8) / / s
Signature of Assessor G1/ O��! Date Signed(date,month, year)
I hereby certify the above is true, correct, and complete. es0
Verifying Action-Signature of Auditor 00 y / Date Signed(date,month, year)
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STANDARD DEDUCTION ALLOWANCE
VA?20 Pay 20 Lesser of 60% of the assessed value of the homestead or$48,000
Notwithstanding any other provision. the sum of the deduct ons provided in IC 6-1 1-12 to a mobile home that $
is not assessed as real property or to a manufact •. -- -•• that is not assessed as real property may not
exceed one-half(1i2)of the assessed value oft •:. o e or manufactured home
Signature o'Auditor Date S gn clh, y year)
DISTRIBUTION: Original-County Auditor File-Stamped •-•y -Taxpaye•
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