Homestead_Roy"'"o CLAIM FOR HOMESTEAD PROPERTY TAX
!° ._,. � STANDARD / SUPPLEMENTAL DEDUCTION
State Form 5473 (R72 / 6-09)
�O � Prescnbed by lhe Oepartment of Local Govemment France
�
���
� ,
�t `�?n `� �.#
i .� �_,
INSTRUCTIONS: See reverse side /or filing instructions. � A i K 1 6� ���
. , � ,
I I�ce of residence or am e u n the tollowin 'bed real ro certiry that i y9�y (our) prindpal
P ( ) yi g g p perty tor which a Homestead Propertya��rp gtiy���� daimed
under conVact on Ne tlate is ppliqtion is filed, (tlate o/filing):
❑ I(We) own ❑!vn (are) buying under recorded conVact
❑ Am (are) entitled to occupy as a tenan�-s[ockholder of a cooperetive housing corporation
� Have a benefidai interest in �he Ws[ or [he right to occupy Ihe property under the terms of a qualified personal residence Wsl
•• � •
Narne o a'unant ( al )
So�l Sewrfly d da'v`unt (fas( d'gE Drivers f n / Identififation /
Name of daimanYs
Sodal Secvriry numbel ot daimant's spouse (last five Cigi�s) Orivefs ficense I ICenti(�tion / Other number Issui�g State
of daimanYs spouse (lasl frve dgi4t)
• ••� �
If buying om m�tract, Fee Simple ownefs reme
Remrdefs olfice where mnvsG is remrdeE Remrd number Page
. . � • • � . •
Counry Township Ta�drg disiriq ( f �p)
rn�
P(J�I� -1 O��O-� (� '� �3� (b a I Is U�e ProPeny in qu�tion:
I propeny ❑ MnuaOy assessed rtn6ile home (/C &1.1-7)
�If any portim o( the revtlentlal swcture w ihe IaM not eYceedvg me (t ) aae that Immediatcy surtountl ac sWtlure is used N pmduce inoome, desuibe the use aM pacion
ot the ryoperty utif¢e0 to produce'v�mme.
• � • • � : • •
Counry Trnmship Caunry Tow�vsttip
I hereby ceNfy the above slatemenis are We, cortecl and complete. � `� � � �
Aress (number aM streef, ury; state, aM Z/P code)
� %(> .-�
,_ , � . •� . �
�� .. �
Land not ezceeding 1 (one) acre immediately .�' 2'' �� �5.-(�'�s � � �' �" +:
surtoundin re5itlentialim rovements. �» az��� �f��`tSt3''� � �`?�.�u�
Olher lantl (2) � �'i�., ��',�,,,t- � ,�`.
Total land (line 1 plus line � (3)
Dwelling (4) ��^��'.K;i�3�,��$3�iif ?:�'uh
Residential improvements or Mnualty
Auessetl Mobile 1 ManufacNred Home Gara e (� ��Y`"�`;:'� 3� j ?�i �,
9 5 :k� �,r ...='i ��s i'�.ii•,_t�,e,�,s.u:;:.=�:..:.
.. � ` _, �, ; ' ;' UL '
Otherimprovemenis (6) y .5;��`.�,-y
Total Improvements (line d through line 6) (7)
Total value (llne 9 phs l/ne 7) (8)
I here6y certiy the above is We, cortect, �9^awre a(ASSassor Date signad (month, day, yea�
and camplete.
Ve�ifying atlim - Signatwe ot Puditor Date signed (monN. day, ysa�
�.-� � � � •
20 _ pay 20 Lesser of 60% of Ne auessed value of Ihe homestead or $45,000
NofwilhsterWirKj eny other0���. Ne wm o! Ne deductions provided in IC 61.1-12 fo a rtrob➢e Mme Naf is g
mtesse sieslpropeM��oamenu/eUUredhwneNatanotassessedesrealpoperrymayroterceed
J the assesseO vafu � the ile home or manulaUUretl hwne.
Sigiu re !ui . Date signeC ( N. Y 1'eer)
'-- � �