Homestead_Welp✓
FOHM HC 10 7979 To & FileA in DuDlicate
ResaiEeE By Sute 6oarE of TaM Cammissioners
CLAIM FOfl HOMESTEAD PflOPEflTY TAX CREDIT FOR YEAR 19 �y
SEE BACK FOR FILING INSTRUCTIONS
�(We) �/r-E-�m • �"-a--Q-�-�- �• ���'^--� � certify that on the 1st day of
�iarch, 19� I, ( e) occupied as our principal place of residence the following described real property for
which a Homestead Property Tax'Credit is hereby being claimed:
I, (We) 1a owned
❑ are buying under contract
❑ have a beneficial interest in the taxpayer
Property Descriptian in �r
Taxing District (Chq-Fewn, Township):
Parcel Number
If buying on contract: Owners name ��� simo�e
nty
ao6-oao��
� u-^-O�'�-� Township
or legal description shown on tax stateme/nt:
��. � c-�J �/� °I - �- - /o ( �• � 8 7 ��
Contract recorded in Recorders Office - Record
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.
� . `�.�0 �9 � 2
•Signamre . � _^ � '� y. Street naaress
r y
County Township
Ciry. Sta:e ana ZiD Caae
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 exceeding 1(one) acre immediately
surrounding residential improvements
Other Land
Total Land � �
Residential Impr medts�
JUN 2 � i97g
Dwelling
Garage
Total
Other Improv�s �
T ' ' Improvemen� Line (6b/� uals (8)
I�by certify the,�bove is true. correct. and complele.
Signamre of
�R ��� ���
True Cash
Value
(1) SO O
(2) 3> ��
(3) ��=-�--�"c_
�a> 3.3oSo
(5) —
�s� 33o sc
(�)
�a� 3 3 o so
Assessed
Valuation
/70
Homestead
Valuation
/ 70
l__- /9- 79
Da:e
Approved: ���c��G�7 Date: l- Z 7- %� '