Homestead_Polk STATE FO1S 53569(R21109) TREASURER FpM TS-IA
APPROVED BY STATE BOARD OF ACT LSITS,bW PRESCRIBED BY ME DEPARTMENT OF LOCAL GOVERS1'ME T FLYAALE C 6-1.1_d,
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
110 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)
ac -a 3- Ito- Too - ooa_ oai-oav
State Parcel Number
a yu S ka.t.L.0-- a 1-126 3 /
. PART 2:TAXPAYER INFORMATION . . _
Owner I First Middle Last
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Mailing Address(number and street,city,state,and ZIP code) ❑ Same as property address
`.
Spouse First Middle Last
Ia ,AS drelL
Mailing Address(Number and street,city,state,and ZIP code) ❑ Same as property address
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. o
Owner I Signature Date
-
�
, FILE ; ,
SEP 2 4 2013
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• INSTRUCTIONS
GIBSON COUNTY AUDITOR
�, e CLAIM FOR HOMESTEAD PROPERTY TAX
- � CREDIT/STANDARD DEDUCTION
'� / Sfate Fwm 5073 (RS / 10-01 J
���� Prescribed by Ihe DepaAment oF Local Govemment Finance
INSTRUCTIONS: See reverse side Ior filing instructions.
FORM � Y AR
Hc,o 6�..
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� M�e) ����m� � q" %r /L(Jl.� .� rl�x/ certif/y �that on the 7st da/y of Marcli, 20
I(We) occupied as our principal place oi residence the following described real property for which a Homestea Property Tac retlt s hereb G t�ied:
❑ I(We) owned ❑ Are buying under wniract � �;—
GIBSON COIR�" � ^<<-• '�`�
�ave a beneficial interest in Ihe entlty that is liable for the property taxes on the property and that owns the property or is buying under a wniraG.
I( 6uying on conVact. Fee Simple owners name
ReroNefs
County
Parcel number
Toxnship
H any poAion af Ne residentlal sW ctura w the
of ihe property utilized to produce inwme.
des� ption �(�
' � �r
no� axceeding ona (1 j a lha� im d
-/aa-ooa. o�i-
IRecord numEer I Page
ESCRIPTION�'a�'-.•i�,`�-+�as C',' '��' �t�'.�'-�`,'='y� y�ti`'.srx-s`�i"i
Tating di5ipct (ciry, town, township)
the property in quesUon:
❑ Real pro08M ❑� Mobile Homo f/.C. 67.
surtounds that swcture is used b Oroduce income, describe the use antl portion
��r'�'���=:•;:i�':����--`��' i_7��sTrwoaRn:oenucnoNnuownrice�.a;:.'���v;�:��,��:r���.�;�'��``_�t
20 _ Pay 20 _
Lesser of 1/2 Homestead
Valualion or $6,000 g
Sgnature ofAUditw Date signed