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FOPM HC 10 1979
HescriGeE By State BaarO af Tax Commissioners
To & FileG in MDlicate
CLAIM FOR HOMESTEAO PROPERTY TAX CREDIT FOR YEAfl 19 % �
SEE BACK FOR FILING INSTRUCTIONS O�l�� �a�QL�.00
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 inte est jn the taxpayer �,,/ /_
Property Description in � f� � �County ���--�'�� -�- -� Township
Taxing District (City, �ewr�shi{�: �: r-�--�-�-�e--c��-'
Parcel Number or legal description shown on tax statement:
�c�J ��� 7 � � � /7 �
If buying Ofl contract: Owners name ��re simo�e owner)
Contract recorded in Recorders Office - Record
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.
�_ r i .
County Township
ana zio �e
' 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 -
True Cash Assessed Homestead