Homestead_Simon (4) -. STATE FORM 53540(RI/&IO) TREASURY,CORM TS.IA
APPROVED BY STATE BOARD OF ACCOUNTS.MI PRESCRIBED BY THE ua.ARnICAT OF LO CAI.GOVERNMENT FINANCE IC 6.I.I-12a.1
Gibson County Auditor IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS
101 N.Main Street Individuals and married ed couples are limited to one homestead standard deduction d deduction.As the receipt of this tied ion become
ilii Princeton,IN 47670 more beneficial,there is more incentive than ever for homestead fraud.Homestead fraud causes higher tax bills for all;therefore,
FILE D 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 identifying 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.
APR 5 2011 PART 1: PROPERTY INFORMATION
C Taxpayer Name Location Address
v r\ Simon, Eugene J Jr/Margaret R
— GIBSON COUNTY AUDITOR _ 12748 S 450 W
. HAUBSTADT IN 47639
9880 '
:I
Eugene J/Margaret R Simon Jr. I IIDI I IIIII101111 IIII I I I:01111 II:IiiIL11:11111lnl:I I I IIEII III011'IIiil1 II
12748 S 450 W
Haubstadt IN 47639-8656
IIIIIIIIIIIIi'iIIIIIIIIIIIIIIIIIIIIIIIriiIII'IIIIIIi'i 11111IIIII State Parcel Number Legal Description
26-22-16-300-000.910-024/ PT SW 16411 .43 AC
This form MUST be returned to County Auditor's office.
Please do NOT send this form back with your tax payment to the county treasurer.
R PARTJ_TAXPAYER INFORMATION - ______ __
- Os.. t First Middle . Last
M,0 >r6 � rt S % ✓tio ✓I
Mailing Address(number and sweet.city,state,and ZIP code) N S 6 v.....-: f Same as property address
'(I, nt aoYIti1tiY NG (Aef4- adI-- 1- ( 16JG
Spouse First Middle - Last
Mailing Address(Number and street,city,state,and ZIP code) 0 Same as property address
a, a l >z o
•-
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
FORM HC 10 1979
PrescriGed By Sta�e Bw�E al Ia. Commissioners
Ta Be FileE in Duplicate
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT FOR YEAR 192�
SEE BACK FOR FILING INSTRUCTIONS
��We) �'��+� � ����� ��� �/��-� (-�-- certify that on the 1st day of
�aarch, 19_Z�, I, (We) occupied s our p iYncipal place of residence the following described real property for
which a Homestead Property Tax Credit is hereby being claimed:
I, (We) O owned
❑ are buying under contract
❑ have a beneficial iry�erest in the taxpayer
Property Description in ���'
Taxing District (6it-y, Tewf� Township):
Parcel Number
If buying on contract Owners name ��� simo�e aw�e��
�D � - �0��� d0
��-da �G-�-�a� ra -�a�
:ounty Township
or legal description shown on tax statement:
��7: Su>%L i�-y-i/ ��, sa�-�a�.
Contract recorded in Recorders Office - Record No. Page
If any portion of the residen[ial structure or the land, not exceeding one (1) acre that immediately surrounds that
structure is used to produce income, describe the use and portion of the property utilized to produce income
Any other counties in which individual owns or is buying real property: County Township
�hereby certify the above statement is true, correct and complete.
�,�s�s
�°�,�. 2 . ��> �Z i �3 � i � � ��, ��� � ��� 3
gnamre Street A ares� Ci:y. ca�e ana Zio Cotle
' Individual either owns or is buying under a contract that provides he is to pay the property taxes
on the residence, or has a beneficial interest in the taxpayer.
- FOR ASSESSOR'S USE ONLY -
Land not exceeding 1(one) acre immediately
surrounding residential impr�aq�s � � �
Other Land 1
Total Land
Residential Improvements �U� 11 1g7g
Dwelling
� e
�
AUDITO
Other Improvements
To��' Improvements - Line (6) plus (7) equals (8)
I�ry certii�q-�E�ie above is true. correct. and complete.
Signa:ure oI Assesme
Approvetl
True Cash
Value
��� S o O
(2) 3 3 3 0
(3) 3 � 3 o i'
(4) / 7s�n
�5� s o c
(6) zz � o
�>> i �- o
(g) � 3 (o O
- ACTION BY AUDITOR -
Assessed Homestead
Valuation valuation
' � ������������
.. i .
Date:
7