Homestead_Van MeterC
CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD/SUPPLEMENTAL DEDUCTION
S� .~ State Fa�m 5473 (R72 / 6-09)
�O � Prescribed by Ne DepaMrenl of Local Govemme�rt Frence .
INSTRUCTIONS: See reverse sitle !or fifing instroctions.
��
FORM
HC10
YEAR
�(we) �/�,� 1,!/ d/ �— vW /l.. Y� L(�/IV L ceNfy that I(we,c1 ocwpied as mny (our) prindpal
place of residence or am (are) buying the following desuibed real properry for which a Homesiead Property Tax S�6Td I�e�c1�a8 �uhereby daimed
under conVad on the date Ihis appliption is filed, (date o/filingj:
❑ I(We) own ❑ Am (are) buying under recorded conVaa ��
❑ Am (are) entiUed to occupy as a tenant-stockholder of a cooperaGve housing corporation �CG �
� Have a beneficial interest in ihe Wst or the right to occupy the property under the terms of a quali�e�j$$hlldl@�d7dlhi8'4MkiDITOR
Ea•^J7'
Name o( tlau�unYs
OmeYS Grx�ue / ItlenUfira�
num0er of tlaimanYS spouse (lasf five tligtls) Drive/s licer�se / Itlentifiration I Oihe
• ot Uaimant's spouu (las! five dlgits)
11 Euying m contract, Fee Simple rnmeYS rume
RemrOers office where mniracl is
Counry
� bd—�� `�'-i�"a�
udentlal strumre or Ne W�d not exceedifg rne (1) aire lhat
m pmOUCe inmme.
Township
I hereby certify the above statements are we, cortect and complete.
Land not e:ceeding 1(one) acro immediatety
nurrounding residential improvements.
Olherland
Total land (line 1 plus line �
ResldentlallmprovemenborAnnualty �����g
Ilssessed Mobile I ManWachired Home Garage
Olher improvementa
Total improvements
Total value (line7 phc Ilne 7)
I here6y certiy the above is We, correct,
and complete.
Veifying artion - Signawre M �tor
��)
�Z)
(3)
(4)
(5)
(6)
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(B)
SgreWre at Assessor
Recard numbrl Page
• • •
Taimg CisiriG (dty, fawrt tox ip �.✓ �
I�ihe pmperty rt� qu�tim:
Y U��%' assessed rtroh7e home (IC 6-f.1-n
is useE tn pfoduca incorti¢, desttibe �he use and portion
20 _ pay 20 Lesser of 60% of Ihe assessed value o� �he homes[ead or $45.000�
Nofwifhslaritlug eny other provivon, Ne sumW the deductions prouded in IC G7.1-i2 to e rtnb,le home Nat As g
rrot assessed as real property w to e manWeCUreQMrtie Nat is rwt essessed as real propeliy maY not ertned
Dafe signed
Date sigrred �ron(h� Oay '
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