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16
CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION -
State Fortn 5473 (R2 / S92)
INSTRUCTIONS: See reverse side for liling inshuctions.
FORM YEAR
HC10
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' CERTIFICATION STATEMENT `�
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I(We)���� lL c rh that on t� 1st day of M ch,
I(We) occupied as pnnapa place of resi c e foliowing descnbed real property for which a Homeste ro `T�;C . .ishEr �med:
�(We) owned ❑ Are buying under coniract �'�'/ z�^S''" r� `' ���� �`���T��
❑ Have a beneficial inierest in the entiry that is liable for the property taxes on the property and thai owns the property or is buying under a contract.
� CONTRACTRECORDED -
If buying on contract, Fee Simple ownets name
Recorders office where contract is recwded � Fecord number Page
PROPERTY DESCRIPTION
Caunry Townsl�ip T" disirict (`ciry, town, fownship) ,
Parcel number Legal description
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If arry poNon ol ihe residential structure or the land not exceetling one (1) acre ihat immediatey surrountls thai structure is used ro produce ixome, descnbe Ne use antl ponion of
ihe properry utilizetl m praduce income.
PROPERTY OWNED BY �CLAIMANT IN OTHER COUNTRIES
ICounry Township Counry Township
'gnature ol � nt
�ereby certify lhe above statements are We, correct and complete.
Adtlress (numbe� and street. ciry, sfare, � code) � � �� , � T- N � f � (07 �
% / /% �
ASSESSOR USE ONLY TRUETAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land not exceeding 7(one) acre immediatety (��
surrounding residential improvements.
Otherland (2) ,
Total land (line 7 plus line 2J (3)
Dwelling (4) -
Residential improvements
Ga2ge (5)
Other improvements (6)
Total improvemenGS (line 4 through line 6) (7)
Total value (line 3 plus line 7) (8)
I hereby.certify the above is We, correct, and Signamre ot Assesor Date signed
complete.
Verifying action - Signature of Audiror Date signetl
i STANDARD DEDUCTION ALLOWANCE
19_ Pay 79 _
Lesser of 7/2 Homestead S
Valuation or 52,000
Signawre of Audimr Date signetl