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3'O w. . A
CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD/SUPPLEMENTALDEDUCTION
State Portn 5473 (R72 / 6-09)
Prescnbed by Ne Depannreni of Loml Gmertment F�rce
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ma i nw i �vrvs: see reverse s,ne ror h�mg msmictions. - "yyi ��
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��e) cerlify Ihal I(we) oaupied as my (our) prindpal
place of residence or (are) buying Ihe tollowing descn ed real property t which a Homestead Property Tax Standard DeduUion is hereby daimed
under conVac[ on the date this appliqUon is filed, (date ol filing):
�I(We) own ❑ Am (are) buying under recorded conUacl
Am (are) enlitled [o occupy as a tenant-stockhofder of a cooperative housing corporation
� Have a beneficial interest in the Wst or the right to occupy ihe pmperty under Ihe [erms of a qualified personal residence Wst
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Nazne of tlaunant (kgal namej �
Name of daimanYs spouse (legal name)
Sodal Sea�riry number ot tlaimant's spouse (lasf frve tligtis) Drivefs license / Identification / ONer number luuing State
of daimant's sp�wse (las( Irva dlgiLS)
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If buying om m�tract, Fee Simple ovmers nama
Remrdefs oRrP where contrad is remrtleE Record number Page
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��y Tv.mshi0 T' d' '(rity, town, tawnship)
Pamd num1p¢r Legal AesaiOtim Is Ue �oPerty in ques�im:
' \ 3 � ^ � � 3 ^ �_ Real property ❑ MnuaOy assessetl mohile home (IC &1.7-7)
�If arry portion ol Ne residenlial sWCWre or Ne IaM not exceedifg one (1 J acre Nai immadiatety wrtounds �hat sWCture is useC m produce irimrne, descnbe the use antl portinn
l Ne property utif¢ed tn pmduce inmme.
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CounN 7ownshiV Counry 7ownsAip
I hereby cenify the above statements are We, correct and complete. S' f imam �
AGtlress (number aM street, ciry, sf21e, and LPOOda)
W. So beA� Ln. F, r�nc�t /U 7(0
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Land not exceeding 1(one) acre immedlately � '�._��, �:� �s:.5„�' 1i��?#Y
surroundin residen6al im rovements. � 1 Z�� -�,. *'�u �.� :t�'"v ,,,u:s.u:�
Other land (2) � "' � ���t' 3.'
Total land (line 1 plus line � (3�
Dwelling (4) ��t..'�-� '+ ����.cyx"� ia �
ResidentlalimprovementsorAnnualty c�-. ��.>Y?"�
Auessed Mobile / Manufactured Home �a�8e �5� �',i'' +�+i r� ,����„�'.�.�{�,r��.
Otherimprovements (6) 3^'�t ' ��iF'Z'�-��
s. ,,-t fi '
Tofal Improvements (line 4 fhrough line � (7)
Toql value (I/ne 3 pl�s Ilne n (8)
I hereby certify the above is true, cartect, Signaaue otnssessor Date signad (mmfh, day, yea�
and complete.
Vaih�i� acUOn - SignaN`e of Audimr Date signeC (�U� day, yearJ
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20 pay 20 Lesser of 60% of the assessed value of the homestead or $45,000 �
Nolwit�staMirg any ofher provision, Ne sum d the deducfions provitletl in IC G7.1-7Y ro a mob�7e home Mat is S
not essessed es real pioperty w la e menNadured home Nat is rrot assessed as real properry meY �t exceed
onMatl(12�W Ne assessed rdlue at Ne rtpEYe lame ar manWaUUred horne.
sigria re ma,aiwr _ oate sigriea (rnonN. ear. r�A
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