Homestead_West� � _� � ' _ _ _
n.
� CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Form 5473 (RB / �-IXi)
Prescribed by Ne Department of Local GovemmeM Finance
INSTRUCTIONS: See reverse Side /oi Iiling insfmclions.
FORM
HC10
YEAR
I�e) 9~' P P rtY certify thaPop ��151( ay��� Y. 20
1(We) occupied as our principal place of resi nce the fo n descnbed real ro e for which a Homestead Pro e�Ry�T Cie 1 r b daimed:
❑ I(We) owned ❑ Are buying under conUact � �� n��
//
❑ Have a benefidal interest in lhe entity Nat is liable for the O�oPerty taxes on the property and that owns the rqqefty, o yl pdere�¢oh U.
I( buyug on conVacf, Fee Simpe ownefs name
ofice where mnVaq is remrded
Record number � Page
� �wy /� � cn(y/Uoq/� is the property in question: •
' �N ��/� 7 / ��� �b �Real property ❑ Mobile Homo (I.C. 67J-7) .
H any portion of Na resitlantial sW cture a ihe Wnd not exceeding one (1) aae ihat immediatey surrounds that sW cture is used to D�uce income, describe the use anC portion
of Na prapeAy utiize0 b produce income. �� /��
(O
County
I hereby cerli(y the above statemenls are We, wrted and complete.
�. (num6ei aM sVeef, crt}; stafe, ZIP
/� #� . ,/S�n/ asi
Land not exceeding 1(one) acre immediatety
surrounding residential improvements.
Other land
Tdal land (line 1 plus line 2)
Dwelling
Residentiel improvemenfs or Mnualy
Aasessed Alobib I AlanufacNred Hvne Garege
Other improvements
Tdal improvements (line 4 through line 6)
County
�D �i� c�4ti.. �, �/? ( 7 Q
� ; �TRUE NC��,��- �ASSESSED;VALUE��. �HOI
,-i�'�-e� ��'VAI:UE� �. 3AT�00°/a'OF�,"TfV� ��'
I�)
(2> ��
..�
(3)
(4)
(5)
'a'3:�s
�6� ���``
�, �=..
(�)
Tctal value (line 3 plcs line n (g�
I hereby certiry the above is W e, corred, and Signamre ornssessor
complete.
Vaifyim� action - SignaNre o(PUdimr
Tavnship
DatB 5igned
Date signed
E�" �^fi�cr.; � '_�S f" K� � . .. . ...• � ' � . _
«...rti-_.?�:..= �:. ,� ..._ -.x a��+'��-'�:STANDARD'.DEDUCTION�ALL'OWANCEe�'��`.+.�'�.e�"ui'�'..�'����-�"�z.?'":�`z..�----.^"`».snn"``4?��`3..-�a`�.��
20_Pay20_
Lesser of 1/2 Homestead
vewabon a E35.000
S
Sgnature oflu�dflw ' oate signed
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