Homestead_Miller (5) STATE FORM 5356900`17-091 TREASURER FORM TS.IA
APlROVFD BY STATE BOARD OF ACCOUNTS,2009 PRESCRIBED BY 11151FPARTAIEYr IF LOCAL GOVERNMENT FINANCE F6-I.1_61
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 I: PROPERTY INFORMATION
Property Address(number and street,city,state,and ZIP code)
0f22Y L . //di- //( ILED
State Parcel Number J
oao-47a/C - deo_ fl& SP- col,/ SSEEP zuLlijudit-
GIBSON IBSON COUNTY AUDITOR
PART 2:TAXPAYER INFORMATION •
Owner I / First Middle • Last
Mailing Add number ands reef,city,state,and ZIP code) // ❑ properly address
100 707to— au& -AO
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 Part 4 below)
Slue
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 homestead standard deduction on this property. Each undersigned also understands that,by claiming additional
homestead deductions unlawfully,he or she may be liable for back taxes and substantial financial penalties.
Owner I Signature Date
INSTRUCTIONS
My •P A 3 2
� CLAIM FOR HOMESTEAD PROPERTY TAX o1 FORM YEAR
CREDIT/STANDARD DEDUCTION '�j' Hc10 $
` Stata Form 5073 (RB ! 7-07) \�,�
`
Prewibed by Ihe Depanmerri af Local Govemment Finarxe
INSTRUCTIONS: See revarse side /orfiling instruc6'ons.
. .
I(VJe) '+' certiry that on the 1 st day of March, 2p
� I(We) occupied as our pri �pal ace of residence Ne tollo " nbed real properly for which a Homestead Property Tac Gedit is hereby daimed:
�(We) owned Are buying under contract
�Have a benefidal interest in the entity that is IiaWe fw the property taxes on the property and that owns ihe property or is buying under a contract.
If buymg on cmiract Fee Simple ownefs reme
at6ce where con4aa is
Caunry
Townsltip
ParcrJ number L al d cnption
`�fJ� lD - y-l� 3. �30
I} arry poNOn of Ure resitlerNal sWqure w Ihe land not exceedirg ona (1) acre Nat immediati
of Ute property uliGZed b p�oduce incwne.
a Co-aa-ia-a� -oao
Tawnsnip
I hereby certify the above statements are We, correct and complete.
Address (number aM streeG cify, sfate, end ZIP m0e)
Recortl number
I�Y.
Page
I Is Ne prope 9ues�ion:
I pvperty ❑ Mabile Fbme (IC 6f.1-�
� surtounds ihat sUUClure is used to produce inwme, describa the uu and portbn
���-°ay
County
To.vn8hip
�- � � � .� � r
��.•
LarM not ex�rg 1 (one) aae immediatety _ � • - � � �
surrounding residential improvemenfs. (�� � -
Other IarW (2) � - . .
Tdal IarM (line 1 plus line 2) (g)
Dwellirg (q) . � ' -
Residential improvemenis a Mnualy � - .
0.ssessed Mobile I ManNacNred Home .
Garege �5) . - '
O�her improvements �g) .
Tctal improvemenLS (line 4 through lirre 6) ���
Total value (line 3 pl's Grre n (8)
I hereby tertity tlIe above is We, tortett, end SignaWra ofAssessw Date signed (monN, day, year)
complete.
Vaifying adion - SignaWre of Autlitw Date signad (rrronN. daY• Y�/)
�..� � � � •
PeY 2�— 45.000 for 2007 pay 2008 42,000 for 2070 pay 2011
L.nCf OI iIZ qq,ppp for 2008 pay 2009 41,000 for 2011 pay 2072
Homestead Valuation S
w 43,000 for 2009 pay 2010 40,000 payaWe after 2012
SignaNre otlwditar Date s9ned (mmf/t. Oay. Yea�