Homestead_CurlSTATEFOILM33569(A3B-10) TREpSURFA FCµ,��TSiA
APPROVED BY STAiE BOARD OF ACCOIi�TS. _>009 PRESCRI9FD BY iNE DEPAA"fME.\T OF LOCAL CA\'ER\:�.\T Ft.�'A.\CE IC61. �'_'_�e.l
1 / � ' / / , . ' 1 � , 1 � , �
Individuals and married couples are limited to one homestead standard deductioo. As the receipt of this
rleduction becomes 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 ���ho 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 filiugs. This information
will be kept confidential and can only be accessed by authorized county officials. The Department of Local
Government Finance will use this information to create tools that �vill help county officials eliminate
horoestead fraud. i
Taaoarer \�me
Complete and re(urn to:
i �d5�
�r
Social Seamry NianDer pest 5 Eigih) Omera Licensel5ute ID NumEer (lest 5 digits) �• ONm (olease specEy in Patl < Delow�
— � � �
..
Each undersigned certifies, under penalty of perjury, that the above and foregoing information is true and wrrect and that he or she is eligible to receive t
� ; CLAIM FOR HOMESTEAD PROPERTY �AX
CREDIT/STANDARD DEDUCTION
`t /�, SIaleFwmS:7$lR6/4-03� .. , '
Prescobeil by tAe Department of �ocal Govemment Finance 7 - �
� � � • �/( �� 1�
'!�e entity that is I' e for the property taxes on Ihe property and lhat owns the pro����8��5�tixd ��a���.
°: T • h
ry,w�`,..t...vd:;is?�� :�v.�_z ��-Y,�:? :.v-n.K_%:r:`�:>;CONTRACT'RECORDED'•.,"_�S` - ' � .zr'� �' � '-'"` -
I( buying on contact. Fee Simple ownefs name �
Remrders atfice whera contrad is recwded Rewrtl number , Page
County Tavnship
r n mber L I esc' lian
��- 032a_�a� ��
I( any portbn o1 the residan6al swcWre or ehe �and not exceedin9
ot th� properry ufilizeC to produce inwme.
=:��_ �-.: . .
dlSllltl (LI�; fOWl1, fOWlIShIP)
I'�_/�� ^ Is the pmperty in question:
1/,r�_� ❑ Real pwperty ❑ Mobila Homo (/.C. 67.7-7)
� E
aae that dnme0iatey surrounds Ihat strucNre is used to Droduca income, describe Ne use antl portion
a.3a��
r.-._ ..- , _ ._ __ .,. . ..: . . ,-. ._ .__._
' � �'.�'��:,,..�+,-'?�s,'.,,`:,``s`� �:��`itPROP.ERTY-OWNED��BYCLAIMANT;IN�OTHER'COUNTIES„��� ��:'°¢�x."�" -'`�- -� ^.�-�
,.s3�..., n'_ -
County n ^ � � Tonnship - � County .TUVnship
I hereby certify ihe above statements are We, corteG and complete. Sig ture of da' nt
'dress (number and stleef, city, stafe, ZIP code)
. /l r. � S 7
' �� :- 'r �" '�� ��'';'Y�'`��" +��- .`s °�;��� i TRUE,TAX Y � �ASSESSED�VALUE >HOMESTEAD � 3 NON-RESIDENTIAL� t.�"` --
}�i ��i�-��ASSESSOR U�� NLY�y:.��-.;�,��t.Y-�: Sr��yVALUE�' �� ±AT 100°/a OF TTV� �,�.,3.VALUE�'„�? �t�i S; <i'" � ��
�..E ;`Y� °�VALUE--...� rz�*�`_
Land not exceeding 1(one) acre immediatety �,�.,ii ft'���°:`�� k'�„'; �`'y`�`•.
surtounding residential improvemenis. . (�) :_, �`3"� `t��,.,�� � -;-1�.�.'.'
;�YNU �
{4
Oiherland ���i�' 'Y+r
�Z) .: '�?A,�,,���"`-r
rv>,:,..�_��.. :,rs
Tdal land (Ilne 1 plus line 2) �3)
� Dwelling .(4) r�i�s Q!i-�'.� ��x �':3 v y.�;i
Residentiel impmvements or Mnualty � "'�'ry��'�X�'' ��r� � "t`;'
0.ssessed Moble / Manufactured Hane Gara e ��� �i'�w��'u 'v�� ��""� � `�. =�
9 (5) .-.;,Y...ti.�.S _.�y��..in....��.
.: �.ir-F's..�-.�'.,,'-y�-�.
Otherim rovements �=���''��"`�'"'�'"i
P (6) ,.� �;'i��.^��-�"�_;?'�.ir'
To1al improvements (line 4 fhrough line 6) (7�
Tdal value (line 3 pli.s line � (g)
I hereby certify fhe above is true, covect, and sgnamre ot nuessor Date signed
complete.
Vrrityirg action - Signature of ALditor Date signed