Homestead_Winters STATE FORM W69 18=11491 TREASURER FORM TS-IA
APPROVED BY STATE BOARDOW ARUfMS.XB9 PRESCRIBED BY THE DEPARTMENT OF LOCAL GOVERNMENT MANCE IC 6-1.1::-R I
IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS
Individuals and married couples are limited to one homestead standard deduction. As the receipt of this
deduction becomes more beneficial, there is more incentive than ever for homestead fraud. Homestead
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fraud causes higher tax bills for all; therefore, HEA 1344-2009 requires taxpayers who receive the
homestead standard deduction to verify that they are eligible to receive the benefit and to provide .
additional indentifying information necessary to allow county government to better monitor homestead
filings. This information will be kept confidential and can only be accessed by authorized county officials.
The Department of Local Government Finance will use this information to create tools that will help
county officials eliminate homestead fraud. Illt
PART 1: PROPERTY INFORMATION _
Property Address mber and street,city,s and ZIP code)
Address
S �lcedeat 49 C g 2ze1 VA''' 101
State Parcel Number Q y
Og-/i- at/ boa-�.o ,t-aa6 S� •` 9'
dtn•pav i
CO`•
G`85D
. PART 2:TAXPAYER INFORMATION
Owner r I/y/{///(1/�JJ1 First Middle o _ Last
Mailing AdHre (number and city ate,and ZIP code) n Same as property address
S3 S. / / �
/?
Spouse First Middle Last
Mailing Address(Number and street,city,state,and ZIP code) 0 Same as property address
Social Security Number(last 5 digits) Drivers License/State ID Number (last 5 digits) Other(please specify.in Part 4 below)
State
PART 3:CERTIFICATION
Each undersigned certifies,under penalty of perjury,that the above and foregoing information is true and correct and that he or she is
eligible to receive the homest ndard deduction on this property. Each undersigned also understands that,by claiming additional
homesteac-ded tionnlawfully, h or shetmay be liable for back taxes and substantial financial penalties.
nt Date
INSTRUCTIONS
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. Mv1P A- 5a cal
7 ,—'"
CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
SIaM Fortn 5173 (R614-03)
RearnbeC by tM Departr�nt W Loal Govennbnt Fmmxe
/NSTRUCTIONS: See rewf�o atds b�Inp iy6uc8on�
FORM 1 ' YEAR
0
1 � 2��6
�(We) i��� //�(�L.(.J � C/�—Q�u certify that on th tst � of Ma �. 20_
I(We) occupied as our prindpal place oi residence the following described real property for which a Homestead Pro��Tikt62�i16k1HErAN�tlf�d:
t ,
❑ I(We) owned ❑ Are buying under wntract
, Have a benefidal interest in lhe entity that is liable for the property taxes on the property and that owns ihe property or is buying under a conUact.
If buying on conVact, Fee Sunple ownefs name
Recordefs ofica where conVaq is
Counry
P/ar'�cel number '�l
hl�/—�Q(�� � -{JCJ
H any portion of 1he residential sW cWre w
ot the property utilaed lo produce income.
Tamship
Toxnship
aae Ihat
1 hereby certi(y the above statements are W e, conecl and complele.
(numbei
Coumy
Record number
Page
Reai Droperty ❑ Mobile Homo (I.C. 67.7-7) .
ire is used W protluca inmme. Aescribe Me use and portion
Twvnship
°__.. .':a ' � A'�r•• .- =-'1 � -� . .-+� .i*�:;a ' �A�.++, wx�.•
_����� �x..��n��'�sF"�?���:sTewoaRaoenucnoN�aLLOw�wce ;���u�.. ��.,�>=-r�.���`��:�'��� r;�
20_Pay20_
Lesser of 1@ Homestead
vauaoon or 535.000
5
SignaWre oi Audhw � Date signetl