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,4� : q CLAIM FOR HOMESTEAD PROPERTY TAX
� CREDIT/STANDARD DEDUCTION
` J Slate Fwm 5473 (RS / 10-01)
Prescribed by the Depanment of Local Govemmem Finance
INSTRUCTIONS: See reverse side 7or /iling insiiuctions.
FORM � YEAR
H�,o aa
I(We�V�� (JY(/ I�. �"' � J v 1S1/�/� �J �/�I�� certify that on the 1 sl day of March, 20_
I(VJe pied as our principal place of residence the following described real property for which a Homestead Propehy Tac Credit is hereb daimed:
I(We) owned ❑ Are buying under coniract
�ave a beneficial interest in the entity Nat is liable for ihe property tazes on the properry and that owns the p perty�r is u' g��r act.
If buying on contacl, Fee Simple ownefs name
RemNefs olfica where coniraIX is recorded
County
Tavnship
Y
V �/\ J
$l I(//�umher C Legal descriplion Is the pmperty in Question:
I�`r-` 01 f�J�� � �.R:�p�operty ❑ MabllaHOmoQ.C.67.1-7)
II any portion of the residential sWCtura w the land not exceeding one (1 � aue t�at immediatety surrounds that sWUUre is used to produce income, desaibe Ne use and portion
ot the property uUlized to produce inwme.
I hereby certify the above statements are true, correct and complete.
i
�ess (numb�r and strret, ciry, s�e, ZlPCOde) _
Land not exceeding 1(one) acre immediately
surrounding residential improvements.
Other land
Tatal land (line 7 plus line 2)
Dwelling
Residential improvements
Garage
Other improvemenis
Tatal improvements (line 4 through Irne 6)
TUaI value (line 3 plus line n
I hereby certify fhe above is true, wnecl, and
complete.
Veritying aclion - SignaWre of Auditor
20_Pay20_
Lesser of 1/2 Homestead
Valuation or 56,000
(�)
IZ)
(3)
i4)
(5)
(6)
��)
I8)
Signamre of Assesmr
3
Trt i:..["•`•
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Date signetl
Date signed
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Synature of Pudita � /� �� I Da�gned �(' C, �
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