Homestead_Wallace (6)�
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CLAIM FOR HOMESTEAD PROPERTY TAX
_ STANDARD/SUPPLEMENTAL DEDUCTION
3 State form 5473 (R72 /609)
�' / PresaiDed by Iha DepartmeM af L.oml Govemme�ri Frerce
INSTRUCTIONS: See reverse side 7w fiiilg insUVC7ions.
FORM
HCtO
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I(We) cerlify that 1(we) occupied as my (our) prindpal
place of residence or am (are) buying Ne following described real property for which a Homestead Pmperty Tax Standard Deduclion is hereby daimed
��u--n//yyder conVaG on �he date this appliplion is filetl. (date of filing):
�I(We) own ❑ Am (are) buying under recorded coniract .
Am (are) entitled ro occupy as a tenant-stockholder of a cooperative housing wryoralion
� Have a beneficial interest in the Wst or the right to occupy the property under the terms of a qualified personal residence Wst
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Name ot Cavnam I neme)
:n Lee ein �
So�
Social Sewriry numbrl of ciaimant's spouse (last five tligds) Drivefs Gcense / Idantifcatian / Olher number Issuing Siate
- of daimarrt's spouse (le9 five d911s)
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tl Wymg om m�hacT, Fee Simple owneYS �me
Remrdels offi�e where mnGaU is recordetl Record number Page
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Counry Township Temig distrid (' fown wnshiP)
ParcrJnum6er LegaldesaiP� IsVie mperty6�question:
a -i -�3-4 I- _O �m ❑�m���u��.,.,-n
It any portim of Ne rrsieential swcwre « Ne la� not ezceeding one (7 ) aae ihat immeElatey surtou s ihat swcare is used m pm0uce inoome, tlescribe tha use and ponion
at ihe praperty WT¢ed b poEUCe u�wrie.
�P c� �� � �9.�.��. �- -
... . . : . .
Counry Township - Counry . TownsNP.
I hereby certify the above statements are We, corteIX and complete. N� � �� �
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reu (numDer and sheet, tiry state� antl ZIPp2de
3a'� N� 1�tleSt J. ����rG/lell l�l- '7 �
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Land not ezceeding 1(one) acre Immediately ..`-�zi'�� �''°��'z'Y��'�s'%€=;
sunou�Min residential im rovements. (�J �.�M t� .Y.-�. �.:5' $�- .'£" sr->�S.fi r.;..
Otherlantl (2) �,-���Ty�
Total land (line 1 O�us fine � (3)
Dwelling (4) � :.,r-`���°����Y£.`+I+ ar LY�
ResidentiallmprovementsorMnually '�'�$ ��"
Assessed Mobik / ManufacNred Home Garege 5 ^�.�s�����`^ k. s�''u-�a��'`�
( J �rF� 1 _� >u� n ,
� r�,y»�:�y's:�#d
Oiher improvemertts (6) .�'�t`;�ws^'b,'�Paa=sd�. .
Tofat improvemenb (line I NmagA Ilne � (7)
7ata1 value (Ilne 1 phc line 7) (8)
I hereby certify ihe above is We, cortect, SignaNre afAssessor Date signed (mmth, Oay, yea�
and eomplete.
Veifyifg actim - Si9naWre oflu�tlitor bate signed (rtron(�. daY. Y��
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20 �,__ pay 20 �_� Lesser of 60°6 of the assessed vAue o� ihe homestead or $45,000
NoMithstand'og any o(herprovivon, lAe sum W fhe dedtrctions prontlM in IC &1.1-72 fo e mo67fe Aortre Nat Is $ '
rrof essessed as iael property a to a menNactured hwne Net is not essessed es real pmpeM meY rwt erceed
one-haX (12) d the assessed value a7Ne mo6de Mme or manufaGUied home.
Sigriature atPUd�r� Date signed (rtpn th. day, yean . .
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