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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
Sta[e Fortn 5473 (R2 / S92)
INSTRUCTIONS: See reverse side lo� /iling instructions.
FORM
HC10 -
YEAR
� t� CERTIFICATION STAT MENT
I(We) ��� �/""'"� �,� ��, certity that on the 1 st day of March, 79_
I(VJe) occupied as our principat place of residence the followi g descdbed real propeAy tor which a Hom� P T�t i e y claimed:
❑ I(We) owned ❑ Are buying under contract
❑ Have a beneficial interest in the entity that is liable for the properry taxes on the property and that ow e pr�e s ying un er a conirect.
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CONTRACTRECORDED
11 buying on contract, Fee Simple ownefs name � -
Recortlefs oHice where contract is recortled CIP$G R,��uurimber��""" ' Page
PROPERTY DESCRIPTION
Counry Tamship Tazing tlistric , mwn, mwnsAi �
i%�so .✓ i¢�;�Cr9� if i D,[�� �
Parcel number Legal descnption
�i -01�,3 �d -oo
II any poNon of ihe residenfial sWCture or the land not eaceeding one (7 ) acre t�at immetliatey sunounds ihat suucture is used to produce income, tlescribe ihe use and ponion ot
Ne property uGlized to pmduce income.
PROPERTY OWNED BV CLAIMANT IN OTHER COUNTRIES
Counry Township Counry Township
Sign of laimant
�ereby certify the above statemenis are true, correct and complete. �
Address fnumber� streer, ury, sfate. ZIP ootle) n
P�I�,E �n..) � (o%Q
ASSESSOR USE ONLY TRUE TAX ASSESSED MOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land not exceeding 7(one) acre immediately (�)
surrounding resideniial improvements.
Otherland (2)
Total land (line 1 plus line 2) (3)
Dwelling (4)
Residential improvemenis
Garage (5)
Other improvements (6)
Total improvements (line 4 through line 6) (7)
Total value (line 3 plus line 7) (8)
I hereby ceAify the above is W e, correCt, and Si9naWre ol Pssesor Date signed
complete.
Veritying action - Sigrature ol Auditor Date signetl
STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _ � .
Lesser of 1/2 Home ad c�
Valuation or S2. 00
Sig�aWre of Audimr Date signed
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