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eE " g CLAIM FOR HOMESTEAD PROPERTY TAX
=!�'E CREDIT/STANDARD DEDUCTION
S
- j Sta[e Form Sa73 (R2 / 5-92)
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INSTRUCTIONS: See reverse side /or liling instructions.
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- ,. . ' � ' .-. /RERTIFICCTI(
FORM
HC10
YEAR
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I(We) - � � certif qq��,�h ye 7st�d��q of March, 19
'e) occu ied as our pri ip I place of residence the following described real property for which a Homesiead��y�Cr�tls�r y Gaimed:
��� If�J a 11 I/
�e) owned ❑ Are buyinq under comract . . "^ l�SJ/
❑ Have a beneficial interesl in the entity ihat is liable for ihe property taxes on the property and thai owns ihe proE%6li10fqi3ri�i�r a contract.
C7ff971 �6
CONTRACTRECORDED.
It Wyirg on contracL Fee Simpie awner's name
Recorders ottice where contract is recorded
Record number � Paqe
-� ��� PROPERTYDESCRIPTION - �
Counry Township . Tazirg districi (cey, tow fow hipl
Pp�cel � e-0o�ga_o o Legaldescnption ^^ / O '�� n` '
Ll el �C ti
If any portion of the residential strucwre or the lantl not exceeding one (1) aae that immetliatety surmunds that strucmre is usetl to produce income, descnbe ihe use and portion
of the properry utilizetl to pratluce income.
� PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES
County TownsNp Caunty TownShip
�reby certify the above statements are irue, correct and complete. Signaw� ot ciaiman� .
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Address (number and stree�. dry, siate, ZIP oode)
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ASSESSOR USE ONLY ". � TRUETAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land not exceeding 7(one) acre immediately
surrounding residential improvements (�� �
Otherland (p)
Total land (line 7 plus line 2� (3)
Dwelling (4) .
Residential improvements .
Garage (5) �
Other improvemenis (6)
Total improvements (line 4 through line � (7)
Total value (line 3 p�s line � (g)
I hereby Certify the above is trUe, correCl, and Signature of Assessor Date signetl
complete.
Veritying action - Signature of Auditor Date signed
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19_Pay79_
Lesser of 1/2 Homesiead
Valuation or 52.000
STANDARD �EDUGI IVN ALLUWANGt
S
\/ I /'�J_/ — — I Date si4n-d
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