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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Form 5473 (RB / 4-03)
Prescribed by the Depariment of Local Gavemment Finance
INSTRUCTIONS: See reverso side /or /iling instnicfions.
FORM YEAR
� C1
I(We � l7W ( rti(y ihal�o e 1 y o 20
I ) occupi as our principal place of residence t (ollo ng escribed real property for which a Ho ' g�p�e� f.�e�(,ag�l(p�b , daimed
I(We) owned ❑ Are buying under contract
� Have a benefidal interesl in the entity ihat is liable for the property taxes on the property and Ihat owns the property or is buying under a wnVact.
I( byMg on conVacl. Fee Simpie ownefs name
Re�mdels ofice whera contraq is
Record number � Page
County � 7avnship Taing datrict (dry, town, townshiP)
Pya�rcel number [ eg description Is ihe pmperty in tion:
v — � ��1��' � Real property ❑ Mobila Homo (LC. 6f.7-� .
H any portion of the resiEential sWCWre w the land not exceetlinp one (1) acre that immediatety wrtounds ihat suuGUre Is used b produce income, desaibe the use and portion
of Ne proDehY �Wized b produce income.
� � h-°.� -�-� s �--
Coun�y
Tawnship
I hereby cerUry the above statemants are We, corred and complete.
Addreu (numbe, and streef, ciry, sfate, Z/P code)
Land not exceeding 1(one) acre immediatety
surtounding residential improvemenls.
Other land
Tdal land (line 1 plus line 2)
Dwelling
Residential Improvemenfa o� Mnualty
As.sessed �Ao61k / AlenufacNred Home Ga2ge
Other improvements
TUaI improvements (line 4 through line 6)
Total value (line 3 phs line n
I hereby ceitify �he above is We, corred, and
complete.
Verih�ng action - Signature oflwdiWr
r)
�z)
(3)
(4)
(5)
(6)
l�)
(8)
Signature of0.ssessor
Counry
signed
Data sgned
``"�rt���."�F __ :�"�"�'�'���i���.,sTnrronRO oenucnoN�A�iown►ice:s�''s:.�.���:�'�-'�.'����'�?��`�`
20 _ Pay 20 _
Lesser of 1/2 Homestead
velua�n or f35.000
S
Signature of AuSrtw � Date signed