Homestead_UngethumI, �'����)
A+arch, 1
( � �: o�.sty
CIAI��i FOR H���STEAD FROP�tTY TAX C.R�DIT FOR YEAR 19�
SEE BACK FOR FILING IN57RUCTIONS
-�-r'`���
�r�'`a
7 �� �y„�_ certify that on the lst day c
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I, (�.Ie) occimigl as our rincioal �lace ot residence th_ follaving des¢ib=_d real
wnich a Haimstead Prop°-rty Tax Credit is hereby being claured:
Z, (i�'e) � a•meri
� are bu�inq urrier contract
� have a beneficial interest in the ta�aYer
Pro�rty Description. in !�r-a.ox- _ n��ti'
_ Ta.�.ing District (City, Tw:r� �rns ll- _ TQ.�.o.,�
��sc�l ijw�io•� or legal des¢intion sho�wn on t�c statarnnt:
�� �t% �f �� .s-,�-io za.o
DD�-Doaao
Towruhi
'I= Dllt':.I1Q om m�tract: Owr.�ss n�c'e (fee sur�1= ow-ner) �
Co;��.ract r�.rordsi in P°�rd=r's O°=ice - F��card D3�. Page
If any oor,ion of the residential stn:cture or `h= land, not e.�e�ing one (1) a¢e that
irnvsiiately surro�s �at stn�cture is used to produce incam_, des�ibe th_ use arrl oortien of
the oroo�sty utilized to producs inco7re
Pny other mLmties in o.�hich indi�2d•�al a�ans or is bv�ing real proo�_rty: Cb�tv 7Q•.r.shiD
,? h=�ny c�-`,�,iy the above s�atem�t is true, o�rrect ar�i con�1°t_•
� �/ (% � - # 3 �it�-,���,�c_� 5� �6 �o
Ctraat_ ��AS25S C1�jr S�t° dIYl L�A CA[I`.
v
*Incividual eith°r aans or is buying �er a mntract that provids h= is tn oay `_
orot�.°_rty taxes on :he residence, or has a beneiicial interest in tite ta�:oayer.
- Ff1R ASSESS(h'2`S USE OtdLY -
Land not ex��g�l ���a�r , �atnl.y
surrour3ing re aefi'� airarovarens
�-� � . r�aR � �98�
To�i �a
;.� �,.
P�sidential _ A,��'.�
C`�h�r Im?rov�-nts
Dwelling
Garaae
Zbtal
True Cash
Val+�
(1) � o 0
i2) f % f�
t3) �'d°
(4)
(5)
(6)
(7)
� �. ?r�ivvenp�ts - Lins (6) plus (7) �is i8) (B) _
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Z h�re�y c.stiiy the abov°_ is true, corre� � znd ocz�mlete.
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