Homestead_TateiOflM HC 10 1979
Prturibed By Sute BoarO of Tar Commissianers
To & Filed in WD���ate
CLAIM FOR HOMESTEAO PROPERTY TAX CREOIT FOR YEAH 19 � y
SEE BACK FOR FILING INSTRUCTIONS
�(We) �— � �• J� �• certify that on the 1st day of
arch, 19 �` , I, ( e) cupied as our princi place of residence the following described real property for
which a Homestead Property Tax Credit is hereby being claimed: .
i
I, (We) ❑ owned �O� ' DI�'�
❑ are buying under contract
❑ have a beneficial intepre/st ,.in the taxpayer
Property Description in !�-�-�—�a Countyr ��'`-'�` Township
Taxing District (Cii�r-�own, Township): \���Za-'
Parcel Number or legal description shown on tax statement: /
�o� , �� �i� �? / — a - io ( 3, t/i,
If buying Ofl contract: Owners name ��� simo�e owner)
Contract record� in Recorders Office = Record No. Page
If any portion of the residential structure or the land, not exceeding one (1) acre that immediately surrounds that
structure is used to produce income, describe the use and portion of the property utilized to produce income
Any other counties in which individual owns or is buying real property:
�hereby certify the above statement is true, correct and complete.
��� �=� oL� Q �� .2�� Z
�/ 'Signatur� Street ACEress
County
Township
Ciry. Stare ena Zip
' Individual either owns or is buying under a contract that provides he is to pay the property taxes
on the residence, or has a beneficial interest in the taxpayer.
- FOR ASSESSOR'S USE ONLY -
Land not exceedinp 1( qn,e) aere im�diatet
surrounding reside�l ii�prov�e�ments� �
t�
Other Land
Total Land ;�"� � 1 13��_
Residential Improvements
Dwelling
� , ��r2�cs� Garage
� AUDITOR Total
Other Improvements
Tr' Improvements - Line (6) plus (7) equals (8)
I�by certiTy the above is true. correct. and complete.
Signawre ol
�
True Cash
Value
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(2) /�-0
(3) /'�z'`"o
(4) �.S (�/c
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(�)
(8) � J � � o
- ACTION BY AUDITOR -
Assessed
Valuation
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Da:e
Date:
Homestead
Valuation
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