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CLAIM FOR HOMESTEAD PROPERTY TAX
rt, � STANDARD / SUPPLEMENTAL DEDUCTION
S`v Staie Form 5473 (R72 / 6-09)
' / Fresaibed ny ure Departmem m Lom� corermiem Frexe
FORM YE�
10
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INS/RUGIIONS:Seerevel5esitlelo�filirginSfNCtiOns. Au � LU,
� (`/'/e) . . ce �y as my (our) pri�pal
place of res�dence re) uying the t lowing described real property f which Homestead Pmp��j�7aac Sfandard Dedu n is hereby daimed
under conVact on the date ihis application is filed, (date of filrng): UfJ COUNTY qUDITOR
❑ I(VJe) own ❑ Am (are) buying under recarded conVact
❑ Am (are) entiiled to occupy as a tenant-stockholder of a cooperative housing corporation .
� Have a benefidal interest in the Wst or the right W occupy the properry under Ne terms of a qualified personal residence Wst
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N de' t me
Sode� SeartiC/ �umbef tlaenant 6 d'
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Nama ol dairurtt' spouse (legal name)
Sadal Seauiry twmbu of Uaima s s ds) Drivers Grznse / IdenMkatian / O�her
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If buying on con5act, Fee Simple ownefs riama
RecorCefs otfice where conveU is rem�deA � Remd number Page
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counry rovmsnip ravng aisma (dry, fown, rownsnip)
P Le9al Eesoji�Vtion Ne in quesibn:
"' �� (T O� I property ❑ MnuaOy assessetl modle home (IC 61.1-n
ol Ne � �uC�T¢ed�toe�u tr��e Um IarM not exreetli`q me (1) aae Nat Immediatety su Nat 6trucWre is used to produce inmrt�e. CesMbe Ne use and portian
iiPla
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Counry Township Counry Townsltip .
I hereby ceNfy the above stetements are We, cortect and complete. Siyrem t daimam - �
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ACdress (numDer and s�p(, ury, stafe, and LP code) � � ���
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LanA nOt eiceeding 1(one) atR immediately �.=�;� ���{.=��i'�" �y`""s3_,
Surtoundin re5ldential im rovemenls. (» �ri.��'{�'m3�F�.^��°,^ �,.;,�' � �,��
Otherland (2) r�y'.s�'�R"�s �
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Total land (line 1 plus line � (3)
�'�`g" �' g-��-�'�i���'�
ResltlentlalimprovemenborMnualty �Iling (4) �,�g,�� x��s,_'n.
/lssessed Mobik 1 Manufactured Home Gara e �`yn''�R�?i x��,�I5�p�- a��c
9 �5� € �riS�l.�:?(i-ri�a�F'"c .#,3.`�'S..�.
c � �£'
Other ImpmvemeMS ' (6) ' ���'�„4��t�{
Total Improvements (llne I thio�gh line � (7) -
Totnl value (llne 3 plu line 7) (8)
I hereby eertify the above is we, cortea, Sg�nue oi nssasmr Date signed (monr�, eay, year�
and complete.
Veityi�g aaian - SyriaW re otividitor Date signeC (manN, daY. Y��l
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20 _ pay 20 Lesser o( 60% of Ihe assessed value of Ne homestead or 545,000
NWwifhsfaMUg any ather P��*sim. fhe sum W the tleEUCtionx pro�itled in IC 6f. f-7P to a mob�le Mme fhat is $
nof essessed as real poperty w to a menuhdctured hwne Nat a nof asseaed es real properry may rrot erceed
ane-ha (7 o/the assessetl vefue o/Ne mo6lle hwne w manufarlured home.
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