Homestead_Hook (2) Reset Form
CLAIM FOR HOMESTEAD PROPERTY TAX YEaR
1' y ,= STANDARD I SUPPLEMENTAL DEDUCTION FORM
HC10
\s f. State Form 5473(R20 r 12-24)
Prescnbed by the Department of Local Government Finance
INSTRUCTIONS See reverse side for Ming instructions
NOTE Telephone Social Security dnver s license. state identification and federal identification numbers are confidential under IC 6-1 1-12-37
CERTIFICATION STATEMENT
I (We) J II •
a # IFF I. II certify that I (we)occupied as my (our) principal place of
residence or am(are)buying the following .-- nbed real p y under contract for which a Homestead Property Tax Standard Deduction is hereby claimed on the
date t application is signed (date of signature) I (We)
Own .1 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 nght to occupy the property under the terms of a qualified personal residence trust
Arn (are)the shareholder partner or member of the entity that owns the property
/
CONTRACT RECORDED
If Buying on Contract Fee Simple Owners Name
Recorders Office Where Contract is Recorded Record Number Page
PROPERTY DESCRIPTION
Coca• Town jor.A ' Taxing Dr cl(c to,crsh,p)jr
/q/A fejt, ii)/0
- /iSCYL-S /1-77)K/4-
Parcel Number Legal Description Is the property in question
eal Property ❑ Annually Assessed Mobile Home(IC 6-1 1-7)
If any portion of the residential structure or the land not exceeding one(11 acre that immediately surrounds al structure is used to produce income.describe the use and portion
of the property utilized to produce income
(.: 6, -iz (.1 (7 , C - ,;? , 4-00 - 0 62,S7
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State Co n ,and T '*ship Is Clai nt Vacating a Homestead?
/ - .11550 f r t� ' Yes ❑ No
/ Signalu t Claimant
I hereby certify the above statements are true, correct, and complete. /% '•""^14, }L` /( ! . /_
':: . .f vacated H st rf anynull�� er`an• treat, c st to d ZIP de i
Ad. of c„gntar n tier d city sta and ZIP code) /J ( ` 1 O
ASSESSOR ONLY 1 ASSESSED VALUE HOMESTEAD VALUE NON-RESIDENTIAL VALUr-
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) F LFEr
Annually Assessed Mobile/
Manufactured Home Garage (5)
Other Improvements (6) '
NOl� 2 120 _ .,..
Total Improvements (Line 4 through Line 6) (7) i►
Total Value (Line 3 plus Line 7) (8) `
Signature of Assessor Gigs
'B �5.� e (date month year)
I hereby certify the above is true, correct, and complete. ON coJNry pQ��, tt,e4;7s4J
Venfying Action-Signature of Auditor Date Sigri2d�&Tier.year)
STANDARD DEDUCTION ALLOWANCE
20 Pay 20 Lesser of 60% of the assessed value of the homestead or S48 000
Notwithstanding any other provision the sum of the deductions provided in IC 6-1 1-12 to a mobile home that
is no assessed as real property or q a manufactured home that is not assessed as real property may not
exc one=half(1/2)of the ass ed value the mobile home or manufactured home
Sig tun of dd 01 Date?rg/+el AI da
.,c
J i _i40 i I i
DISTRIBUTION: Original-County Auditor. File-Stamped Copy- Taxpayer
lJ
Page 1 of 3