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INSTRUCTIONS: See reverse side (or filing inshuctions.
FORM
HC10
YEAR
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CERTI CATION STATEMENT
I(We) certify that ont �th�e i st duay o rch, 19_
I(We) occupied as our principal place of residence the following described real property for which a Homesiead PropertyQ�ainC�tlH i y claimed:
❑ 1(We) owned ❑ Are buying under contract _
❑ Have a beneficial interest in the entiry thai is liable for the property taues on the property and that owns the p�erty or is-� in r a.
GIBSON COI;NTY AUDITOR
CONTRACTRECORDED �
If buying on conVacl, Fee Simple ownefs name
Recorders ottice where mnVact is recorded Record number Paqe
PROPERTY DESCRIP N "
Co n Township Tadn dis[rict ciry, , fownship)
arcel number Legal description
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If any portion of the residential structure or the land not ezceetlinq one (1) acre hat � ediatety s ounds that sWaure is useA to produce income, tlescribe the use and portion of
the pmperty uWizetl to praduce income.
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PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Township Counry Tovmship
SignaNre of tl ' ani
ereby certify the above statements are true, correct and complete. � �
Adtlress (number anC sfreef, ciry, sta(e, ZIP pode)
�R ax s 4ubsfadf z�v ����
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land not exceeding 7(oneJ acre immediately ���
surrounding residential improvemenis.
Otherland (2)
Total land (line 7 plus line 2) (3)
Dwelling (4)
Residential improvements
Garage (5)
Other improvements (6)
Total improvements Qine 4 through line 6) (7) �
Total value (line 3 plus line 7) (8)
I hereby certify the above is true, correCt, and Signature of Assesar Date signed
complete.
Verifying ac6on - Si9nature oi Auditor Date signed
STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _
Lesser of 1/2 Homestead . S
Valuation or 52,000
Signai r of Auditw Date si
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