Homestead_Loyd4 _n•" CLAIM FOR HOMESTEAD PROPERTY TAX
., STANDARD / SUPPLEMENTAL DEDUCTION
State Fortn 5473 (R12 / 6-09)
�O � Prescribed by the Depanmenl of Loral Govemment Finance
INSTRUCTIONS: See raveBe side lor filing instruUions.
F '• � � , _
6 `' It �',�
•
� iWe) � � • . certify that I( ocwpied as my (our) prindpal
place of r i ence or am (are) buying the following described real propeAy for which a Ho stead Property Taa Sian r�c�,ion' ere6y daimed
un r co a on ihe date ihis appliration is filed, (date ol filing): �
� (We) own
❑ Fvn (are) buying under recorded contract G�$SO� CpUNTy q�DlTOR
Am (are) entitled lo occupy as a tenan4stockholder of a cooperative housing corporetion
� Have a benefiaal interesi in ihe Wst or the right to occupy the property under Ihe terms of a qualified pereonal residence Wst
•- � �
Namaof imant kgalname) • _ n
� C LCLt-{ �
'
�
Sadal Sewriry number o1 daimant's spouse (last �rre as) Dmrels ficense / Identification /
/
. .-� .
If buying om m�tra0. Fre Simple ovmefs riame
Retnrdefs ottxx where mnvaG is recnNed Record number Page
..�. . � . �
Caunry Townshi7 Tam9 is �(city, Wwn. towrW�iO)
Parcel number L desmption � I �y �he pro erry in Question:
i
eal property ❑ Annualy assessetl modle home (IC 6t. f-n
�If arry porG Ne residentlal swcW(e a Ne land not ezceed'u�g orre (7) aaa that immediatety wrtoun Iha swc¢ire a used m p�odure Irrvme, des<xibe the use aM partion
of the p�o utif¢ed to produce inmme.
a�-19-i9- �dv_voa. o3�-oa�
-.. . , : . .
Counry Township Caunry 7ownship
I hereby ceRify Ne above statemenis are We, correct and complete. Sg re of daimam f �
�-n��� i .
ACdteu (numDer antl sveet, riry, slate, anqLP cade) .
c s , /'� %� �l7��/.�'
. . .� . �
.- .
�� ..
surtoundirnx residentie�m�ro emenadiauty ��� �„�'v-`f.� t�iY.��."F�-��"`,�y�`
f..ra..a'i' ]... �.;...
Other land (2) F��i .5'�"���SV���-
Total land (line f plus line 3) (3)
Dwelling (4) ��}: n� ��by,y-tir'� na =i-
Residentlal improvements or Mnualty "-•'^;' z �'i� � '"''�"' 'T
Assessed Mobile l ManNacturetl Home Gara e }'�t-�'� �z`^KU �'� � �'"� �
9 (5) S'ti�.xr..S_.s„�a�n:�3il��.F'`."�uNw..;r'r:�:
.., c•..�. . . �_.,
Oiherimpmvemenfs (6) ���°�'X.;'�` .
1,;_.s:• �v
Total Impmvemenb Qine o Nrough Ilne � (7)
Total value (line 9 pAs I/ne n . (B)
I herehy certify ihe above is true, cortect, Signatura otnssessor Date signed (monN, eay, ysa�
and camplele.
Vailyu�g action - SignaNre of Puditw Date signed (rtronf�. daY. A��)
�..� � � � •
20 pay 20 _ Lesser of 60% of Ne assessed vAue of �he homestead or $45,000 �
NoM1VifhsfaMirg any o/harprovisiori. Ihe sum o71he datluctions provided in IC 8-1.1-12 ro e mobile home Naf is g
not essessed es real propelry or fo a menuFaUuied home Nat is not assessed as ieal property maY not esreed � -
ane-hal/(1R) W Ne asseuerl valua W Ne mo6de Mme or manutdrtured hwne.
Sig�Wre NAUtlitnr Date 5i9neE (monN.Oay, yea�
�