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v NikeT CLAIM FOR HOMESTEAD PROPERTY TAX 1 YEAR
41111110, STANDARD ! SUPPLEMENTAL DEDUCTION FORM
FDy Slate Form 5473(R20 I 12-24) HC10 2_0 Z
• •- 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) 1 S.ttI1►` rrId ` t � certify that I(we)occupied as my(our)principal place of
residence or am(are)buying the follo rig des bed real property under contract for which a Homestead Property Tax Standard Deduction is hereby claimed on the
date this application is signed. • f 9• �S (date of signature). I(We)
awn. Arn (are)buying under recorded contract
E Am (are)entitled to occupy as a tenant-stockholder of a cooperative housing corporation.
E Have a beneficial interest in the trust or the right to occupy the property under the terms of a qualified personal residence trust.
C Am (are)the shareholder,partner,or member of the entity that owns the property
If Buying on Contract, Fee Simple Owner's Name
Recorder's Office Where Contract is Recorded Record Number Page
PROPERTY DESCRIPTION
Township Taxing District(city,town. township)
SQ-n•
Parcel Number legal Descnption Is the property in question
ear 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 porton
of the property utilized to produce income.
LS) oC) \ . CIU) - CO 1
PROPERTY OWNED ELSEWHERE BY CLAIMANT
Stale. County and Township Is Claimant Vacating a H stead?
__ Yes No
Signature of Claimant
I hereby certify the above statements are true, correct.and complete. teitaiL-
Address of Contact(number and street, city state, and ZIP code) Address of Vacated Homest d,rf any(number and street,ci state and ZIP code)
• gl .sri 06 \ 41k I .... • 1---k-1 •
ASSESSOR USE ONLY ASSESSED VALUE HOMESTEAD VALUE NON-RESIDENTIAL VALUE
Land Not Exceeding One(1)Acre Immediately (1)
Surrounding Residential Improvement
Other Land (2)
Total Land (line I plus line 2) (3) Pitt
Residential Improvements or Dwelling (4)
Annually Assessed Mobile I
Manufactured Home Garage (5)
Other Improvements (6) SEP
19 �(1 Total Improvements (tine 4 through Line 6) (7) 75
Total Value(Line 3 plus Line 7) (8) �l
S:gnature of Assess , ON�' eW1*-1 *
,date,month,year)
I hereby certify the above is true, correct, and complete. � ' �
Verifying Action-Signature of Auditor Date
�'If�►rth.year)
STANDARD DEDUCTION ALLOWANCE
20 Pay 20 Lesser of 60"%0 of the assessed value of the homestead or 548.000
Notwithstanding any other provision, the sum of the deductions provided in IC 6-1 1-12 to a mobile home that 5
is not assessed as real property or to a manufactured home that is not assessed as real property may not
exceed one-half(1i2)of the assessed value of the mobile home or manufactured home
Signature of Auditor Date S Two(month, day. year
\PANCLSLQ 0 A.ANI-kt 1-"Nti ) _Xft0* C41
DISTRIB ION Original-County Auditor File-Stamped Copy - Taxpaye'
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