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-_-- CLAIM FOR HOMESTEAD PROPERTY TAX YEAR
STANDARD / SUPPLEMENTAL DEDUCTION FORM
HC 10 j '1
State Form 5473(R17/1-16)0_ Prescribed by the Department of Local Government Finance i
INSTRUCTIONS See reverse side for filing instructions
NOTE: Telephone, Social Security, dnvers license, state identification and federal idenbhcabon numbers are confidential under IC 6-1. 1-12-37
< CERTIFICATION STATEMENT
I (We) ,• 1f JC f 4 (,11�' V.iv j &tie / et _ certify that I (we) occupied as my (our) principal
place of residence or am (are) buying the following described real property under contract for which a Homestead Property Tax Standard
Deduction is hereby claimed on the date this application is signed, 02i 0 j 2-1‘2 (date of signature). I (We):
FOwn El 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 right 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 distract(city,town.township
61 bs: In t t 1 iVi'(/ t0 1 a \-
Parcel number Legal description ✓ Is the property in question.
Real property LI Annually assessed mobile home(IC 6-1 1-7)
tf 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
N/ — O —E —
PROPERTY OWNED ELSEWHERE BY CLAIMANT
State,County,and Township Is daimant vacating a homestead9
[] Yes XNo
S•gne -/ 1J,%
I hereby certify the above statements are true, correct, and complete. 4 ) ..ef,v� / ,_ /���
Address of contact(number and street city state, and ZIP code) Address of vacated homestead.if any(number and street. eitrstate./�and ZIP code)
a ,11 e . a IP (fin 10
ta! , .lIL i • . LA I • •
ASSESSOR USE ONLY ASSESSED VALUE HOMESTEAD VALUE NON-RESIDENTIAL
VALUE
Land not exceeding one (1) acre immediately
surrounding residential improvements (1) -_
Other land (2)
Total land (line 1 plus line 2) (3)
Residential improvements or Dwelling (4) FILED
annually assessed mobile/
manufactured home Garage (5)
,
Other improvements (6)
Total improvements(line 4 through line 6) (7) gEn
Total value (line 3 plus line 7) (8) Q 1 3 202,
I hereby certify the above is true, correct, Signature of Assessor Date signed( i • , day, yea.
and complete. '�C T
Verifying action - Signature of Auditor G/8SO e sir9ote (month. . year)
•
STANDARD DEDUCTION ALLOWANCE _ _
20 pay 20 Lesser of 60% of the assessed value of the homestead or S45.000.
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 assessed value of the mobile home or manufactured home
Signature of Auditor 4Q Date signed(month. day,year)
1`"zA .sIsl. (1. � ' a \ PD r(i — t .
DISTRI UTlON: Onginal-County Auditor. File-Stamped Copy -Taxpayer
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