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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Fortn 5473 (R2 / 5-92) '
INSTRUCTIONS: See reverse side (oi (ling instructions.
FORM
HC10
YEAR
.,�'
�_ ,� � CERTIFICATION STATEMENT J �
I(We) certify that on th¢ft�t � W MRfdn 19_
I(VJe) occupied as our principal place of residence the following descnbed real prop omestead Property Taz�Eiedi s�ier�o�y�aimed:
❑ I(We) owned ❑ Are buying under contract �
❑ Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns the pr� r is b' ` P i
! `!.,^r��t _-;;�t�.ry 1'ti.li�in
CONTRACTRECORDED -
It buying on convact, Fee Simple ownefs name
Recordets office where coniract is recorded � - . Record number Page
PROPERTY DESCRIPTION
Counry Township 7acing district (ciry, lown, fownship)
P I num r _� Legal tlescription �
It any ponion of the residential strucWre or Ne land not exceeding one (1) acre thai immetliately surrounds ihat struclure is usetl ro produce mcrome, deunbe ihe use arW portion of
the property uUlized to produce incame.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Township Counry . Township
3 ot c ' t
� reby certiry the above statements are true, correct and comptete.
A r ss (num r and et, ciry, state. ZIP code) "
/
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VAIUE VALUE
Land not exceeding 1(one) acre immediately (��
surrounding residential improvements.
Otherland (2)
Total land (line 7 plus line 2) (3)
Dwelling (4) - �
Residential improvements
Garage (5)
Other improvements (6)
Total improvements (line 4 through line 6) (7)
Total value (line 3 plus line 7J (B)
I hereby certify the above is true, conect, and Signature oi Pssesor Date signed
complete.
Veritying ac6on - Signature of Auditor Date signed _
STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _
Lesser of 7/2 Homestead �
Valuation or 52.000
SignaWre of Auditor Da e signed
�/-S-O�