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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Form 5473 (R2 / 5-92)
FORM
HC10
YEAR
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INSTRUCTIONS: See reverse side /or filing instructions. A. j� y
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CERTIFICATION STATEMENT
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I(We) certi(y that on the 1 st day of M/a�rch, 19_
I(We) occupie s our principal place of residence the following described real property tor which a Homesiead Prop Tax Credit i heF�oy Gaim ':
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❑ I(We) owned ❑ Are buying under contract ' uµ�;.�- 1
❑ Have a beneficial interest in the entiry that is liable for the property taxes on the property and thai owns the property�oiis tiUying undera conhaci'
CONTRACTRECORDED
If buying on contrnct, Fee Simple owners name
Recorders oftice where contraci is recorded • RecorC numher Page
. PROPERTY DESCRIPTION
Gounry Township Ta�ting distritt (dty, (own, tOwnship)'
�µ�nber O�^ ���� Legaldescripti �
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If any poNOn ot the resitlential sirucwre or ihe IarW rnt exceeding one (7 Nat immediatety sunountls that swMUre is usetl to produce income, describe Ne use and ponion of
the pmpeM utilized to produce income.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES -
Counry Township � Counry Township
. ig r aimant
ereby certify the above statements are true, correct and complete. `
Address (numberantl street, ciry, sta(e, ZlPCotle�
ASSESSOR USE ONLY �UE TAX . ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VAIUE VALUE VALUE
Land not ezceeding t(one) acre immediately (� �
surtounding residential improvemenis.
Otherland (2)
Total land (line 7 plus line 2) (3)
Dwelling (a)
Residential improvements �
Garage (5)
Other improvements (6) '
Total improvements (line 4 through line 6) (7)
Total value (line 3 plus line 7) (8)
I hereby ceRify the abOVe is true, correct, and Signature of Assesor Date signed
complete.
Veritying action - Signature of Audimr Dare signed
STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _
Lesser of 1/2 Homestead S
Valuation or $2,000
Signawre of Autliror � ` Date signed ,�
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