Homestead_Perkins _ ___ __ ____ _1
STATE FIRM 13569 tR1 I 7-9) TREASURER FORMTSIA
APPROVED BY STATE BOARD OF AQOIMIS.1(09 PRESCRIBED BY THE DEPARTMENT OF LCCAL GOVERNMENT HHANCE M'6-1.I•114.1
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
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.
PART l: PROPERTY INFORMATION
Property Address(number and street,city,state,and ZIP code) _ _i i j
c12 1 LiR
I 1
State Parcel Number MAR-1 2015
d(0 - lg - Oct - 00 - 000 . 0`1S oc;. .
GIBSON COUNTY AUDITOR
PART 2:TAXPAYER INFORMATION
Owner I First Middle Last
f�1,
Mailing Address(number and street,c. , te,and ZIP code) It``/fame as property address
t�5
Spouse First Middle Last
Mailing Address(Number and street,city,state,and ZIP code) Same as property address
Social Security Number(last 5 digits) Driver's License/State ID Number (last 5 digits) Other(please specify in Pan 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 •mestead standard deduction on this]roperty.Each undersigned also understands that,by claiming additional
homestead deduct'. lawfully,he or she may be liable for back taxes and substantial financial penalties.
Owner I Signatur- Date
I 1
INSTRUCTIONS
CLAIM FOR HOMESTEAD RROPERTY TAX
° CREDIT/STANDARD DEDUCTION
t Stete Form 5673 (R614-03)
' Prasaibed by ihe Departrnent of Local Govemment Finance
� INSTRUCTIONS: See raverse side for filing inshuctions.
FORM YEAR
HC10
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I(VJe) . Sl certify that on the 1 st day of March, 20
I(VJe) occupied es our pri �pal place of residence the following described real property for which e Homestead Properry Tme Credit is hereby daimed:
I(We) owned ❑ Are buying undar conVact
Have a beneficial interest in Ne entiry that is liable for Ne property texes on the property and Nat owns the property or is buying under a conVaa.
If buying an contreq, Fae Simple ownefs name
RecwEers otfice where contract Is recorded
Racord number � Pege
Counry Township T�dng tlistrict (ciry, town, townsAip)
v
Paul number L al d cription Is ihe property in queslion:
0�1- 6� 5-� �' �� S �b al proDerty ❑ Mobile Home (I.Q 6-1.7-�
If any portion o( Me residentiel strucWre w ihe land not exceedinp one (7 ) acre that immediatey surtwnds Nat a clura is used ro produca inwme, describe Na use and pwtion
d Ne property ut@zed to produce income. .� 5�
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..�`.'°`?St'��z'�.,t�rn`�Y`��iy�y'. ����-..-�,'�°:�PROPERTY,OWNEDiBY=CL`'AIMANT.IN�OTHER':COUNTIEB�t£,,.YF:.,s�r�k'3x':`�y. �.?ie•� a F iK'�u;. ="
Caunty To.vnship Caunry Tv.vnchlp .
I hereby certiTy Ne above statements are We, corted end complete. Signanre ot daimant
resa (number and sLeet, city, atate, 21P code)
. ,.����e-a �?Ss "`UTt2Y��'i�Yffit.t'sn.T's.t-^.Sti'E{�+' �-t� F°'TRUE TAX�+. x ASSESSEDtVALUE �HOMESTEAD � • • � . . ._ ' .
,�,^������� �.� ��s��p�}����.,,'�g�s�.i��,,'��`. �Sif�.VALUEi�� y� .��AT.=100%�OF TTYY .�w, -'VALUE c`f s� � � a��k NOH RESIDENTIAL �
...,._,.. . _ ...._'�� tVALUE, .� s � ; ``
Land not exceading 1(one) eae�immediatay . � .. „} K���t?�=�y4r `-�s �� ty� ;
k
surrounding residential improvements. ( � ,z;_ ,{�;;,r:, �-�tt • �y, .� (=<y,, � ,_• F
Otherland � 4 `�
(2) � �^'-' .
; ti. ..
Tttal IarW Q/ne 1 plus line 2) � �3�
�
,
Dwelling (4) "?o- . r-.�� -+, . _r a � -Ss
Residential improvements or Mnualry °p=. ��,r.�±�. � �,z �. ,� _ •.,,
Pssessed Mobiie / Manufadured Home k� h s; � ��-• -
Gare9e (5) - , .. ? -... ° � �,_ .: ��.
: ->.'`
Otpet improvements (g) �
Tctel Improvements (line a Mrough lirre 6) (7)
T�ial value (line 3 plus line � �g�
1 hereby certi(y the above i5 W8, cortecl, end - Sie��+�e atnssessor � Date sipned
complete. .
Verlly"uig epion • SlgnaNre o1 Audita Data Wgnad
:`" '���� _�:r T'_=�i::c��.3..`-'>}���.:t.`s�.::isSTANDARD,DEDUCTION'ALL'OWANCE;, �" -
20 _ Pay 20 _
Lesser of tY1 Homestead g
Valuatlon w $35,000
SlgnaWre of Fuditor Date signed
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