Homestead_Raley�*"'" CLAIM FOR HOMESTEAD PROPERTY TAX
?; STANDARD / SUPPLEMENTAL DEDUCTION
S• State Fortn 5473 (R72 / 6-09)
�� ! p�¢�bed by the Depariment ot L.oml Govertme�rt Friance
INSTRUCTIONS: See reverse side for filirg instnictbns.
FORM
HC10
I(We) vc.vcs�ww— . - ceruryu�a
place of r dence or am (are) buying 1he follovnng described real property tor which a Home ad Pmperry Tax c
under conVact on Ne date ihis applica6on is filed, (date olhli ):
❑ I(We) own ❑ Am (are) buying under recorded conVact
❑ Am (are) entitled to occupy as a tenant-stockholder of a cooperative hnusing corporation
� Have a benefiGal interest in lhe Wst or the right to occupy the property under the tertns of a qualified personal
Remrd number Page
Caunry TovmshiD Tabng disUi -. rown fownsnlp) '
Pa`cel numher al 0esaption � /' L I e p�operty in pueslion:
� (�✓(A./-O � Real property � MnuaDy essessed mobile home (IC G7.1-:
If portion d Ne resi0entlal swcWre w Ihe lar�d exreedi`g (1) ave Nal immediatey surtounds ihat sWCNre is used to proCUrc i�orne, CesaiCe ihe use aM paruon
ot e pmperty utifaed to p�oduce inmma.
��-a3 -l.l - �oo-�od. �rs3 -d a-Y
Courtry
Trnmship
I hereby certiry the above sta[emenis are We, correct and complete. �
naaress ( Gb�rOar�s?leet, cr(y�st� J�Qcu� da) � r ��
� 7 -� �'�
Land not e:ceeding 1(one) acre immediatety
surtounding residential improvements.
Olherland
Total lantl (line 1 plus line �
Dwelling
Residential impmvements or Mnualty
Auessed Mo6ile 1 Manufachired Hwne Garege
Other improvemenb
Total Improvements (Ilne d Nroug� Ilne 6j
Total vatue (ltne 3 plla Ilne n
I hereby certify ihe above is true, correct,
and complete.
Vailying acoon - Sig�aWre oflu�ditw
(�)
�2)
(3)
(<)
(5)
(6)
afASSessor
Caunry "
S' n�d daimani
�� ��_
�J s� �F
20 _ pay 20 _ Lesser of 60% of the assessed value of 1he homestead or 545,000
NotwiNS7aMing anY �erpm�ision. Ne sum o7Ne tletlurliwisWOVided in IC G7.7-12 fo a rtn6de fame Ihat is S
not assessed as resl propeM a to a menufacmred home fhat ic nof essessed es reel pmperry maY �t exceed
one-hatt�f2) o! Ne assessed value o/ the mobtie home or manulaGUred hwne.
unaWreWAUtlitw n
Towns�ip
r,.,� Y � � � �
Date signed (rtronth, tlay, yea�
Date signed (monN, dzY. Y��
Y��
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