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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Fonn 5473 (R2 / S92)
INSTRUCTIONS: See reverse side /or filina instnictions.
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YEAR
- . r t tS 15 2001
CERTIF�CATION STATEMEN �
I(We) ��" e A v/"� 1 ay of March, 19_
I���(W///e) occupied as our principal place of residence the following described real property for which a ome t�r�p��` ��r dit is hereby claimed:
�I(We) owned �] Are buying under coniract _
Have a beneficial interest in the entiry that is liable for the property taxes on the property and that owns the property or is buying under a contract.
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- CONTRACTRECORDED �
It buying on conVact. Fee Simple ownefs name
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Recordels oHice where convact is recordetl . Record number Page
R�r�Ce�nl �N piAn�'
PROPERTY DESCRIPTION
Counry � Towlns -7�-�j Tauing distnct (dry, town, townshipJ
�'I %� S o.� 7 q /o/) �
Parcel number Legal descnpuon
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II any po of Ne residential structure or the land not exceetling one () acre that immedatety surtounds that structur is used to produce income. describe Ne use antl portion of
the Oroperry uul"aed m produce inwme.
a�-/ o? -D �- '�D� -CY��3• 7 98 G a� ��,� -, L��Sa
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Caunry Township . Counry Township
Signa daimant
ereby certify the above statements are true, correct and complete. � �
Address number and sfreet, ry, state, ZIP coUe) �
��`� 1�iPcv�o2,�c_ %�,Q ! �� Rln�<�"m ^1 � '/rvrJ �A�/R �76 �a
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land not exceeding 1(oneJ acre immediately ���
surrounding residential improvemenis.
Oiherland (2) '
Totai land (line 1 plus line 2) (3)
Dwelling (4)
Residential improvements
Garage (5)
Other improvemenis (6)
Totai improvements (line 4 through line 6) (7)
Total value (line 3 plus line 7) (8)
I hereby certify the above is true, correct, and Signature of hssesor Date signed
compiete.
Verifying ac6on - Si9naWre of Audibr Date signetl
�� STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _ .
Lesser of 1/2 Homestead �
Valuation or 52,000
SignaWre of Auditor � Date s neA /� Q