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• d� •"4' CLAIM FOR HOMESTEAD PROPERTY TAX
• YEAR
\c`'r. STANDARD / SUPPLEMENTAL DEDUCTION FORM
s.e•. State Form 5473(R20/12-241 HC10
ilia-' Prescnbed by the Department of Local Government Finance
INSTRUCTIONS See reverse side for filing instructions il` fl/QIL
NOTE Telephone, Social Secunty dnvers license, state identification and federal identification numbers are confidential under IC 6-1 1-12-37
�1 CERTIFICATION STATEMENT
.
I (We) • f 00 a_ certify that I (we)occupied as my (our) pnricipal place of
residence or am (are)buying thh too I p�d r- • p sperty under contract for which a Homestead Property Tax Standard Deduction is hereby claimed on the
ate s application is signed l I ) (date of signature) I (We)
wn _ . Am (are)buying under recorded contract
(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
Am(are)the shareholder partner. or member of the entity that owns the property
If Buying on Contract, Fee Simple Owner's Name
Recorders Office Where Contract is Recorded Record Number Page
PROPERTY DESCRIPTION
County Township Taxing District(ci ow ship)
fo(\ C) 2,0 - 1 OK-0 if\
Parcel Number Legal Description t roperty in question
Real Property ❑ Annually Assessed Mobile Horne(IC 6-1 1-7)
If any portion of the residential structure or the land not exceeding one (1)acre that immediately su un that structure is used to produce income.descnbe the use and portion
of the property utilized to produce income
2,6 -- U.-\ .--- 2-6 / 2-C) 2_ -- i0 (0 .-- C .
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State County and Township Is Claimant Vacating a Homestead/
Yes ❑ No
Sign of Clair," S
I hereby certify the above statements are true. correct, and complete. �. �/
Address of Contact(number and street city state. and ZIP code) (.t. ess of V.cated Homestead. if any (number and street, city. state, and ZIP code)
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 1 plus line 2) (3) pi 4
Residential Improvements or Dwelling (4)
Annually Assessed Mobile I
Manufactured Home Garage (5)
Other Improvements (6) No_k_t -t1)
Total Improvements (Line 4 through Line 6) (7) ��n7�.
Total Value (Line 3 plus Line 7) (8) '�
Signature of Assessor G/ SON Date Signed (date. month.year)
I hereby certify the above is true, correct, and complete. ,Y C • ys
O(y�7},f� igned(date, month. year)
Verifying Action-Signature of Auditor ,q` �� 'TU
Lit)/
I • -
STANDARD DEDUCTION ALLOWANCE
20 Pay 20 Lesser of 60% 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 $
is not assessed as real property or to a manufactured home that is not assessed as real property may not
exceed one-half(1/2)of the ass e of the mobile home or manufactured home
Si nature of Auditorivl
- Date Signed(m nth, day ar)
L
u� ��� H.
DISTRIBUTION: Original-County Auditor. File-Stamped Copy -Taxpayer
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