Homestead_Stevens�' "C:
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CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD/SUPPLEMENTALDEDUCTION
Sfafe Fartn 5473 (R13 / 12-09)
PresrnDed by the Department of Loral Govemment Finance
FORM
HC10
YEAR
INSTRUCTIONS: See reverse slde /nr filing instructions.
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1(We) � certify that I(we) ocwpied as my (our) prindpal
place o( residence or am (are) buyirg ihe fdlo ' described real property for which a Homestead Property Tax Standard D�iqjlio�i�h�byi daimed
�er contract on ihe date ihis application is fil , (date o7filing). I(We): �
C .�.n _ V
Own ❑ Am (are) buying under recorUed conUect
� Am (are) entllled to oxupy as a tenanbstockholder of a cooperative housing mrporatlon GIBS� N
❑ Have a benefidal interest in the wst or the right to ocwpy the property under Ne terms of e qualified personarresidenc��TY AUD{TOR
❑ Am (ere) the shareholder, partner or member of Ne endty �hat owns ihe property.
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--%
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If buyin9 on contrdct, Fee Simple owner's rame
Recordefs of6ce W�e(e conuact is remrded Re<arC number Page
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Counry iw+�shiv Tari� "(�; rown, rownsh' 1
Patcel number Legal tleu+iPOOn '73 4s Ne ProP�Y in 9uestion:
N� N E / 5- S' -/ / � r�� woaem ❑ nN,�ui ���a �bua n� ��c si. i-n
If any portion of the �esidenUal sWcture or ttre IarM nol exceetling one (1) aae ihat immetliatey surtounds that sWClure a used to produce i�oma, Oesaibe Ue use and portion
a tha poperry uti0zed m proAUm income.
�_ aa_ i s_ �oo_ooa. y�-o �.�
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Counry Tamship CamN T�WP
I hereby cerOfy Me above statements are true, correct and complete. of nt
Adtlress numbe street. dry, sfate. arM ZIP cod / r.� � � ���
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Land not axceeding t(oire) acre Immedlatey +-�'�" ��"�' d"��. -����,
s�moundin residentlal Im rovemenfs. (�) � y� '�'� ' f" .�°-�.
:n ".:;". �Fy,}s,i;,;a,� `- -
_"s _9_X.. � �.,
Othar lantl �2) �..:ti �r�^,:,.:;:'��.-K.�_
Total land (lirm t plus liire 2) (3)
Dweliln 4 � � 3r� �`� ^��'+��,�,v,`��
ResidenUal improvements orAnnuafly g � � � " � �' "`� '
�sed 6lobile I Manufaz4�red Hortre Ga�9e �5� f� ,},� ��h^ �^F `-`�"'�3 f"�'..'--s-.�
a_
Other Improvemenu (6) � �^k-s.�. �
Total improveme� (li� / Nrough lina � (7)
7otal value (line J plls One 7) (8)
I hereby cerdfy the abova Is We. cortect, �e^a�re of Assessor Date signea (monN. deY. i��)
and wmplete.
Veifying acllon - Signature ot ALditnr Date sig�ed (rronN, day, yae�
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20 _ pay 20 Lesser of 60% of the essessed velue of the homestead or $45,000
NofwithsfandNg arry Nherpovision, fhe sum o7Ne deductions proviUetl in IC Gf. f-72 ro e rrob�7e Mme that is $
not essasseU es reel property or ro e menWactured home Net is not essessed as real property meY rwt erceatl
«,e-naa ryrz1 aure essassed �„e oirne mowm nane o�,�en�tecnrred no�.
Signanue of P�Eitw
Date signed (month, tlay, ysa�
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