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""" CLAIM FOR HOMESTEAD PROPERTY TAX
STANDARD/SUPPLEMENTAL DEDUCTION
S' State Fortn 5473 (R12 / 6O9)
�O � Prescribed by Ihe DepaRmenl of Lo�l Govetrvnem Frrerne
FORM
HC10
YEAR
INSTRUCTIONS: See raverse side far filing instiuctbns. �
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I(We) � certiry i���(�) qcq{pj� as my (our) prindpal
place of residence or am (are) buying th Ilowinq described real property Fw which a Homestead Property Ta��S}�n r�D� on is hereby daimed
under mnVact on Ihe date this app�inlio s filed, (date o/filing): C,� �
❑ � M'e) own ❑ Am (are) buying under recorded contract
❑ Am (are) entitled to occupy as a tenant-stockholder of a coopere6ve housing corpore6on G�BSON COUNTY AU�ITtOR
� Have a benefidal interest in ihe Wst or the right tn occupy the property under the terms af a qualified peisonal residence s
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Name W cla'unant (legal name) .
Sadal Smsry rualbx W (6st fi�.e tlig3tJ � D' efs ficenu / Identifrstlon /
Sadal Sewriry mimEa of tlaimanYs spouse (last frve dgds) Drivers Gcansa / IEPntifcation / Other number Iss�ring Sta's
� of daima�rt's spwrse (last !rve dgils)
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If buying om m�trap, Fre Simple ownGS �wne
Raorde�s otfirt where mntrati k remrde0 • Record number Page
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Caunry ToM+uAip Tamg d'p ' ip)
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P I nu r— • ���� Is ihe pioperty in 9uesfim:
I prope.rty � AnnuaAy ¢ss¢ssed rtpd'le home (IC &1.7-7)
Ii any portion of Ne resdential swmre p Ihe la� not exceeAirq aro (7 ) aae ihat trnmeEiatey wrtoun ihat strurL�re is used to pmduce imm�e, Oescnbe the use aM portion
of Na pmperty wTaetl b pmdum income.
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Counry ' Trnmship � • Counry Tmnsship
1 hereby certify ihe above ststements are We, corred and complete. �tur o( daimam � �
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ress (number aM streel� � �te, a ^LPOOde) � � � N � , /
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land not exceeding t(one) acre immediatety �!" ?`�,'t �`y*'_� �^�"{?-�'}�.-y:S
surroundin re5lden�ialim rovements. ��) .�'F-,��-���"C.;.'�: ��,..��[",*,��.ar
Otherland (Z) ����j��r,
7aUl land (line 1 plus line 2) (3)
Dwellin d `� � "��'' 't ��'�'fi
ResldentialimprovementsorMnualy g � � �_ ��"�i�����!`'t�
Assasud Mohik I Manufactumd Home Gara e � �"�
� g is) ��xr�'�`,4„,.��-r.:v.7��.`r�,��%�.�.
Y� v" .' �Y
Other improveme� (6) °� `�.4` �_
�`=§y�?`K;�+�ir�. E,;
Tofal improvemenis (llne 1 NrougAllne � (7)
Total vatue (lJne 3 plls l(ne 7) (B)
1 hereby certify ihe above is true, corted, Signature otASSessor Date signetl (mmlA, day, yea�
and complete. .
Vedyi�g acoon - SigraWre of Audrtor Date vgned (rtanth. tlaY. Y��)
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20 pay 20 _ Lesser af 60% of the assessed value of Ne homestead w$45,000
Notxdhsfaritling any afher pmvision, Ne sum Wlhe tleduclions provded in IC 67.1-72 to a mobi7e home Nat is $ '
nof assessed as real proparty a ro a rtanuhactured �ana Mat k nof essessed es real poperty may rrot exceed
oneJiaM(1R) d assassetl rWUa W Ne mo0ie home w manulertvied hwra.
5 m f i Date ' fh, da , '
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