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e" CLAIM FOR HOMESTEAD PROPERTY TAX
� _ STANDARD/SUPPLEMENTAL DEDUCTION
S State Fo�m 5473 (R72 / 6-09)
�� � Prewibed by Ure Department of Local GoverrvneM Fraxa
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FORM YEAR
"��,Y 2 20
!'.7.n� � V
INSTRUCTIONS: See reverse side fwfilirg instructions. � �
COUNTY AUDI7�
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I(l^/e) ceAiry that I(vre) occupied as my (our) prindpal
place of r iden am ( e buying Ne following described real property for which a Homestead Property Tax Standard Deduction is hereby daimed
under ct on ihe date this appliralion is filed, (date of filing): ,
❑ I(We) own ❑ Am (are) buying under recorded contract '-
❑ Am (are) entiLed to occupy as a fenanFStockholder of a caoperative housing corporation
� Have a beneficial interest in ihe Wst or the right m occupy the pmPerty under the tertns of a qualified personal residence Wst
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Name o1 daunant (legal name) �
e 5 r
Sode15earily nm6a ol tla'vrenl lasf fise dg3s) Drivris Iirense! Id tltkaCOn / Other number Lsw'vg Sate '
-- a aa�n ��u e�e a�xs� /
Name of tla6nani'S spwse (lepal name) - -
Sacial Securiry numbv o1 daimant's spouse (last five dgds) Dmrefs license I Identifration / Other number Issuing Slate
. of daimant's spouse (lasl fire dgits)
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If bu�Nig m contraq, Fee Simple ownefs wme
RemrOers o16ce wt�e�e contrad is 2cade0 � ' Rttpd number Page
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Caunry Tamshi0 T' G'(c1N. township
`4
ParrnJ number . Legal EesaiPtion . Is Ure poperty in puestian'
' / _ —/0 �� wovenv ❑ Annwuy assessed moWe hane Gc 5-f. i-7)
If any porUpf d the residan�Wl sWCNre a Ure IaM nW e�¢eedug ane (1 J acre Nat immediately surtourMs thal sLUrlu�e is used to pmdure inmme, desrnbe Ne use and portbn
of Me P�Pen1' uhTaed ta pmtlure uimme. ,
a�-�a -/9-yoo �o .y�3 -o� �
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Coumy Township Counry Towrt.hip
I hereby ceNfy the abore ststements are true, corteG and complete. Sig daimam p �
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Atltlress (number and slreet, dry, sla;e, aM LP code)
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Land not ezceeding 1(one) acre immediatety � z-'�' �r'c'��` �
surtounAin resl0ential im rovements. (1) �`^ ��^�'� �-.��� ��
,�'� -i.,--�<-._�._ _4_
Other Wnd (2) � ��'�;�,�;s"`�fk�
Total land (line 1 plus line 1) (g)
�h�5� � a
ResldeMlallmprovementsorMnually �����g (4) -��+`�-���"����
0.ssessed Mobile / ManuFacW red Home �..:.5 � T�'-:�"� �' !s
.�.� �`�.e c..°"..,��'�.,,k��+Y
Garege (5) i,i r�t 3�.. ��±s ��v"��,'Ar�'.x M
^rc;-. i,yi hp
OlherlmProvements � (6) ' ��:z�.�;?���
7oUl Improvemenfs (line d through line � (7)
Total value (Ilne 3 plla line 7) (8)
1 hereby certi(y the above is We, torteM, Signature otASSeswr Date signed (mrnN, day, yea�
and complete. '
Vaify'uig aaion - SigreW re at �tor Date signed (rtmnlh. daY. Yfa�)
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20 pay 20 Lesser of 60% of Ne assessed value of the homestead or $45,000 .
NMwitM1Sland'ug enY oNe�provision. fhe sum W Ne deODU.'ens pro�i0ed in IC E7. i-71 to a rtroW7e hwne Naf !s S
f10� 855BSSBd 85l@8� plUpCll)' Of f0 8 lilBllfd'dfl(/lB(� iMRIB I/1816lIW BSSBSTB� BS 1E8���lI}� Rldj� llOf EYCBB.'�
oralwN (1R) d Me assessed ralueW Ne mobde Nane a rtunu7aUured hwrie.
Sigriavae Mt��W�d,il�ar Date sip�reC (mmfh. daY. Yea�
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