Homestead_Tieken STATE FORM 53504(Y)r&10) TREASURER FORM TS-IA
APPROVED BY STATE BOARD OF ALTOII:TS.Mpg PRESCRIBED BY TI:OER.UIME\r OF LOCAL CAvutsmaYr FINANCE IC 61.1324.1
Gibson County Auditor IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS
101 N. Main Street Individuals and married couples are limited to one homestead standard deduction.As the receipt of this deduction becomes •
Princeton, IN 47670 More beneficial,there is more incentive than ever for homestead fraud.Homestead fraud causes higher tax bills for all;therefore.
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
N arfilings.This information will be kept confidential and can only be accessed by.authorized county officials.The Department of
• .il- r i..j .2,..._... Local Government Finance will use this information to create tools that will help county officials eliminate homestead fraud.
PART 1: PROPERTY INFORDLATION
P PR 1 8 e II Taxpayer Name Location Address
C Tieken, Jeff/ Karla Jo
12352 S 200 E
01580N COUNTY AUD TON HAUHSTADT IN 47639
3075 0
Jeff/Karla Jo Tieken II-I[IIII DIIIIIII - III [II I_DIIIfllIll II-1II01111 III-III1111I_IIIDII. fillII IIII
12352 S 200 E
Haubstadt IN 47639-7972`
ilYllllllIllt1111' ' ' 'II'II"I'litlltlllltt4illilll1tllri1lll1t State Parcel Number Legal Description
26-23-16-200-000.646-024✓WARRENTON 25PT/26
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 \ PART 2: TAXPAYER INFORMATION l;,
lT ,.Middle Last
J� F� 4FirSt - Ken
Mailing Address(number and street,city,state,and ZIP code) Same as property address
/ 35.0). s �o6 1...- -7139
3 First Middle Last
iq CIA" MaiiingAddress f umber and"streee,c od
ity'state;and ZIP __ _ f;Sanloas property-address ,- -
/a)3a S 400 Lt—t-- 47O3 .
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
•
ry� � CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
'�, � Sfate Form 5473 (R4 / &00)
INSTRUCTIONS: See reverse side !w fil'ug ins6uctions.
- FORM ,�/� Y R
HC10 �
p b�'
I(We) � K G�v �`�'-�`� certify Nat on the 1st day of March, 20_
I e xw ied as our nnci al lace o resid fh f lowin described real ro `T� ��� ���
(W ) p p p p g p perty for whirh a Homestead R�opaSty�ai Ciedit is_ he{eby d, _ auned:
5
❑ I(We) owned ❑ Are buying unde tontract �s.� « i�L�
�ave a beneficial interesl in the entity that is Iiable for the property taxes on the property and that owns the pro erty or is buying und ra,eontreG.
•] 71�(1'/
If buyifg on contracL Fee S"unpie ownefs name
Recordets ofFCe where contract is recorded
It arry porUon C
ol Ue Property
Record number • � PaBe
ESCRIP�TI_O'I
Tacing disVict
or Ihe land not exceeding rne (7 ) acre Ihat immediatey surtounds Nat struUUre is used to v�uce income, describe the use aM portion
���ii�
�d�Q.�i��0�
20 _ Pay 20 _
>ser of 12 Homestead
jlalua,Gm� or 56,000 ,
E
Date signed
/-- 3 -o �/