Homestead_Carnahan (3)wnA+ xc m ie�s
ReuriGM By State BoarG of 7aa Commiuioners
CLAIM FOR HOMESTEAU PROPERTY TAX CREDIT FOR YEAR 19'�
To & FileE in Duplicate
✓
SEE BACK fOR FILING INSTRUCTIONS Q�9' 0O,3�pS' 00
� ,-t,�, �- °1�I.�..v
�(We) 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) �. owned
❑ are buying under contract
❑ have a beneficial interest in the
Property Description
Taxing District (City, Town, Township):
Parcel Number
If buying on contract: Owners name ��� simpie owner�
��—�J Township
or legal description shown on tax statement:
/� ii-, CL / 3 �
Contract recorded in Recorders Office - Record No. Page
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.
County
Township
a.� �%�7C�
GiiY. Stare anG Zip GoGe
' 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 immetli`�t�ly
surrounding residential'(yt�pqo� �qIS
/J
Other Land � -
Total Land
Residential Improv ents���/�"��
AUOlTOR
Other Improvements
True Cash
Value
(�) �� �
(2) — ° —
(3) Sc�
Dwelling (4) �6�
Garage �5� �3�?-�
Total (6) 9���
7� Improvements - Line (6) plus (7) equals (8)
�._.aby certify the above is true. coyr�ct. and compl
Signa:ure oi Assesmr
��T• i
ACTION BY AUDITOR -
J
Assessed
Valuation
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Dare
Homestead
Valuation
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Date: � 7