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CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD / SUPPLEMENTAL DEDUCTION
State Form 5473 (R12 / 6-09)
�O Prescribed by the Department of Local Govemmem France
INSTRUCTIONS: See reverse side for filing instructions.
F YEAR
HC70
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101 201!
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CERTIFICATION STATEMENT
iWeJ certify that I (we) occupied as my (our) principal
place of residence or am (are) buying the following described real property for which a Homestead Property Tax Standard Deduction is hereby claimed
under contract on the date this application is filed, (date of filing):
❑ I (We) own ❑ Am (are) buying under recorded contract
❑ Am (are) entitled to occupy as a tenant - stockholder of a cooperative housing corporation
❑ Have a beneficial interest in the trust or the right to occupy the property under the terms of a qualified personal residence trust
INFORMATION
Name claimant (legal name) I/ -
�/,j�_ —
Name of claimant's spouse (leg" rho)
Social
d buying on contract, Fee Simple owner's name
Recorder's office where contract is recorded Read number Page
PROPERTY DESCRIPTION
County
Township
Tammg district (W. town, township)
Parcel number
Legal descripbon 7 . / oIC
Is IAe property in question:
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S 54) ps J — _ / Q
❑ Real prop" ❑ Annually assessed mobile home (IC 61.1 -7)
Pms of the residential structure or the land not exceeding one (1) acre that immediately surrountls that structure is used to produce Income, describe the use and portion
Iff Ne property utilized to produce income.
01lo- os -as= Soo -o0 /. �(if 0o -'00
ROPERTY OWNED r
County Township County Township
I hereby certify the above statements are true, correct and complete.
� n�`,1 of dai i
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�J�it
Address (number and street, ci[�ty, state, and LP code)
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ASSESSOR USE ONLY TRUE TAX VALUE 1 ASSESSED VALUE r
Al V
Land not exceeding 1 (one) acre Immediately
(1)- ryy °�"�`N`-
surrounding residential improvements. s�4?�i -�.
Other land
(2)
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Total land (line 1 plus line 2)
(3)
Dwelling
(4)-
7� h
;,,'- '•4'.''?�,}'�A.
Residential improvements or Annually
Garage
(5)
„S 5k
r .. R
Assessed Mobile I Manufactured Homo
Other Improvements
(6)fi
,•
Total Improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(6)
' hereby certify the above Is true, correct,
Signature of Assessor
Date signed (month, day, year)
and complete.
verifying action - Signature of Auddor Date signed (month, day, year)
STANDARD v v
20 pay 20 _ Lesser of 60% of the assessed value of the homestead or 545,000
Notwithstanding any otherproveuon, the scan of the deductbns provided w IC 61.1 -12 to a mobie home that is $
not assessed as reel pmpeny or to a manufactured home that a rot assessed as real properly may not exceed
one4off (112) of the assessed valve of the mobie home or manufactured home.
Sigraum olpu!C _
Date signed (month. day, year)
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