Homestead_WethingtonFOFM HC 10 19i9
fieu�iGeO By State BoarO o� ia� Cammissione�s
CLAIM FOR HOMESTEAU PROPERTY TAX CREDIT FOR YEAR 19 �9
To Be Filea in Duo�iwte
SEE BACK FOR FILING INSTRUCTIONS
��We) �ETt/in�GTa/, f7f120LD F �E3,2A certify that on the 1st day of
� arch, 19��, I, (We) 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)�ned
❑ are buying under contract
❑ have a beneficial interest in the taxpayer
Property Description in �'��O^-!
Taxing District (City, Town, Township):
Parcel Number
If buying on contract: Owners name ��� simo�e ow�e��
bo6-dao��
tY / AroiC F) Township
or legal description shown on tax statement:
�/�GA,O fficcs �or 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.
1 �. � .� � � -
'SignaNre
Stree�
County
Township
Ciry. S�ate ana Zio Coae
Individual either owns or is buying under a contract ihat provides he is to pay the property taxes
on the residence, or has a beneficial interest in the taxpayer.
�i I : � FXY��Y� ] :7 6Y � b9 �iP►1 _A !
Land not exceeding 1(one) acre immediately
surrounding residenlial improvements
Other Land
Total Land � � � � �
Residential Impr me Dwelling
JUt� 7..: i979 Garage
/�j4� Total
Other Improve� �
-�T�� � Improvements/� Line (6) ��T(�equals (8)
b,y certiiy ihe aboveas true. correci. and complete.
�L.e �1"�.
ASSM30�
True Cash Assessed Homestead
Value Valuation Valuation
(�) /OPO 330
(2)
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(8) ,ci�
- ACTION BY AUDITOR -
330
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Approved: �- ��,�/���'� Date: G�27-7 j