Homestead_Yockey�
CLAIM FOR HOMESTEAD PROPERTY TAX
i,_ STANDARDISUPPLEMENTAL DEDUCTION
State Form 5473 (R12 / 609)
S / arexrioee ty ure oevertmem ot �omi co�rerr�rem Frer�
INSTRUCTIONS: See reverse side (or filing inshucfions.
FORM YEAR
HC70
I(We) �/ � certify that 1(we) ocd�igl^a rintipal
place o( residence or am (are) buying e following dexri I properry fw whi estead Property Tax Standard Dedudion is h b imed
undercontraaonNedatethisapplirationisfiled, (d teoffiling): G�gSON COUNTY AUDITOR
❑ I(We) own ❑ Am (are) buying under recorded conVad
❑ Am (are) entitled ro occupy as a tenant-stockholder of a cooperaWe housing corporalion �
� Have a benefidal interest in the Wst or the right to occupy the property under Ne terms of a qualified personal residence Wst
Soaal Securiry rwmba of tlaimant's spouse (last five dgrts) Drivefs Gcense / Identi;calion / Olher number
of daimarR's sPWSe (last (rve OFg'2s)
If buymq on contra4 Fee Simple ownefs rame
mntract
�
town.
Is Ihe ppperty ui Qu��on:
Issurt�g State
Record number � Page
- � d' O�T /- ./(o'{ib(E7 � woa�r LI AnnuaM assessed maWe home (IC G1.1-
�If any portion of Ne resdential swcWre a Ihe lard not axceedlrq am (7 ) ave that immetlia[ely wrtourMS Ihat snucW'e b useC to proEUre incane, dewibe ihe use and porUOn
af Ihe property utQ¢ed to P�uce inmrtie. '
�
Twmship
I hereby certify the above sfstements ere We, corteG aM complete.
Pddress (num6er and atree4 �1: ��e. en0 LPCOtle)
O 2oU �. Go S-rG0.- %'T'
land not e:ceeding 1(one) acre Immediauty
Otherland
7ata1 land (line 1 plus line 2)
Residential improvemen� or Mnually �����9
Assessed Mobile / Manufaceiretl Homa Garege
Other improveme�
Total improvements (line 0 througA fine 6)
Total value (line 3 phs Ilne �
1 hereby certify the above is we, cortect,
and wmplete.
Vaifying actlm - SignaN2 oTAUditw
Counry TownsNp
�� �`
�kt �
9 g -��! ��- G�7�c4-
i+).
c2i
(3)
(4)
(5)
(6)
�)
(8)
S�riaWre of Asseswr
20 pay 20 _ Lesser ot 60% ot ihe assessed value of the homestead or $45,000
NMxiNxfeMUg enY �rprovicbn, Ne sumW the detluctions provbed in IC Gf. f-12 M a mobde hwne Nat is
mt assesseE as ieal properry w lo e manulactured home fhat a nof eue.ued as real propeily may rat arceed
oneha/Vff11 W Na assessed i¢IUeW Na mo0de �ome or rnanulactured frome.
$'
�Y Y��)
Date s�gneE (monfi, daY. l��)
Date