Homestead_Sollman (10) •
STATE FORM 53569(R235-O9) TREASURER FORM TS-IAI
APPROVED BY STATE BOARD OF ACCOUNTS.2009 PRESCRIBED BY THE DEPARTMENT OF LOCAL GOVERNMENT FINANCE IC6-1.1.22-9.1
e 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
•auses higher tax bills for all; therefore, HEA 1344-2099 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. •
PA' I: PROPERTY INFORMA ION , -
Tasnaver Name Property Address State Parcel Number Lent Description:
Randolph S/Patty A Sollman °'t' /1'f�-7 S /S O 26-22-11-200-000.954-024 00.1-00954-00 PT E 1 1 4 I 1 659 AC
Haubstadt IN 47639
Complete and return to: 11
GIBSON COUNTY AUDITOR, 101 N MAIN PRINCETON IN 47670
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PART 2: TAXPAYER INFORMATION
Omer 1 / First Middle last
�a4d o /P 4 _ C.- 0 So/479 ,
Mailing Address(number art sbrel city,state and ZIP code) Ime as property address
.
Spouse First Middle Last •
9 //1n /4/74 . 00 //ii9
Mailing Address(nurnaerS street.city.state and ZIP code) O rne as property address
Il `f 7 3 �
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
PART 4: ADDITIONAL IiNFORMA•FION .
• .
•
FORM HC 10 1W9
Pres[nDed By Slate Bwre o� iaz Commissioners
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT fOR YEAR 19.2�
io Be FileO in OuDlicare
SEE BACK FOR FILING INSTRUCTIONS
�(We� a-��^ ����Q• �, CY- certify that on the tst�day of
arc�92.�, I, (We) occupied as o r principal place of resi nce the following described real property for
which a Homestead Properiy Tax Credit is hereby being claimed:
I, (We) ❑ owned ��� ` �� ���`��
❑ are buying under contract
❑ have a beneticial int rest in the taxpayer� ��O?'�� ��'��•���°��
Property Description in ' County Township
Taxing DiStriCt (Gity,—Tnam- Tnwn�hinl�
Parcel Number
If buying on contract: Owners name u� simoie ow�en
or legal description shown on tax statement:
,�' SE �l it/E ��! //- � // � a� v
Contract recorded in Recorders Office - Record No
If any portion oi the residential 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
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;�xreby certify e above staterPent is true, correct and complete.
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. �� � � �
'Signamr I� ^ Sneet naaress Clty. S:ate a o Zio �oae
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' 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 improvements
Other Land � I � E �
Total Land
Residential Improvements ��na 12 i979 Dwelling
Other Improvements
�Garage
� j��1��fotal
auoiroR
To'-�' 'mprovements - Line (6) plus (7) equals (8)
I�._ �uy cerjify�the above ig true. correct. and complete.
Sigriamre ol
True Cash
Value
(i� Sa o
(2) 3 � o
(3) �' 3 0
(a) 3 0 o O
(s) � 5� o
(6) 3 / SC�
(�1 � 7 �
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- ACTION BY AUDITOR -
Assessed
Valuation
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Homestead
Valuation
/ 3 0 �� %
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— Dam
Date: ��-Z9
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