Homestead_Mathurin 'Reset Form I
# '4 CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
STANDARD 1 SUPPLEMENTAL DEDUCTION FORM
1 HC10
- / State Form 5473(R20/12-24)
e.
` ___- Prescnbed by the Department of Local Government Pmance •
INSTRUCTIONS See reverse side for Ming instructions
NOTE Telephone, Social Security, dnver s license, state identification and federal idenhhcation numbers are confidential under/C 6-1 1-12-37
CERTIFICATION STATEMENT
! (V1re) • e_ c4. 411.1 - lk A .a 1 certify that I (we)occupied as my (our) pnnapal place of
residence or am (are)buying the following descnbed real property under contract for which a Homestead Property Tax Standard Deduction is hereby claimed on the
date this// application is signed it • ' - (date of signature) I(We)
, 'bwn 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
0 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
Recorders Office Where Contract is Recorded Record Number Page
PROPERTY DESCRIPTION
County Township Taxing Distract(city.town,tov.,.s, :,
C___•.--; 1\i#Dalaf".\ Me
Parcel Number Legal Descnptio _• Is the properly in question
veer"...
al Property ❑ Annually Assessed Mobile Home(IC fit 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,describe the use and portion
of the property utilized to produce income
c th L `i , Do w "a co - oC . 'sa - Oca I
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State.County. and Township Is Claimant Vacating Homestead's
_ Yes No
Sign ure of Claimant / _
I hereby certify the above statements are true, correct, and complete ill / 'I(�/�A^-- `' 4143,14141.,_Address of Contact(number and street city state and ZIP code) Addr s of Vacated Homes ead rf any (number and street, city. state. and ZIP code)
O : '. . lb - __A, , ' - . - , . t-t-1 I . .
ASSESSOR USE ONLY ASSESSED VALUE HOMESTEAD VALUE I NON-RESIDENTIAL VALUE
Land Not Exceeding One(1)Acre Immediately (I)
Surrounding Residential Improvement ._
Other Land (2)
Total Land (line 1 plus line 2) (3)
Residential Improvements or Dwelling (4) �0 �
Annually Assessed Mobile/ 'k-4- tg
Manufactured Home Garage (5) ���
Other Improvements (6) //_��
Line (7) tl��� ?
ob.Total Improvements (Line 4 through 6) � 41'�O
Total Value (Line 3 plus Line 7) (8) e ((^' Ot3N
Signature of Assessor D Ards e`inonth year)
I hereby certify the above is true, correct, and complete. G` 7
Verifying Action-Signature of Auditor Date Signed(date month year I
STANDARD DEDUCTION ALLOWANCE
20 Pay 20 Lesser of 60�r% of the assessed value of the homestead or$48.000
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 properly may not
exceed one-half(1/2)of the assessed value of the mobile home or manufactured home
Signature of Auditor Date Signed(month, day. year)
N1/44-x .\_,e__if\n_ 0 Q 0.1. (4.Altt_.k."-Ip' g)). \ --1 .. 1
DISTRIBUTI N: Original-County Auditor File-Stamped Copy-Taxpayer
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