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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Fortn 5473 (R2 / S92)
FORM
HC10
YEAR
INSTRUCTIONS: See reverse side for filing instructions. .
' FICATIO TATEMENT ' - � � �' " "� �
I(We) cEH�r'that bh �L�iS{ day of Mamh, 79_
I(We) occupied as our�principal place of residence the following described real pr erty for which a Ho/��¢ stead Property T(,��c Credit is hereby claimed:
❑ I(We) owned ❑ Are buying under wntract Il�� � L �
, 7
❑ Have a beneficial interest in the entity that is liable for the propeity taues on the property and thatAv{asihe.prope�.{jr �r; buy'� er a contract.
CONTRACT RECORDED
It buying on coniract, Fee Simple ownels name
Fecorder s oHice where contraci is recortled . fiecortl number Page
PROPERTY DESCRIPTION
oun Township Taxing district (ciry, o fo ipJ -
aR41 numbe� Legal description
U ��/ a ( �-Oa � �
II any ponion of Ihe resitlential structure or the land not exceeding one (1) acre t at imm iatety surtounds that struaure is used to produce income, tlescribe ihe use antl portion of
ihe p�operry utilizeA ro protluce income. �
PROPERTY OWNED BY CIAIMANT IN OTHER COUNTRIES
Counry Tovmship Counry TownShip
s�g� irriani �J
.Stereby certify the above statements are We, correct and complete. � K-�->,/ �"1
/ —TJ cJ
(number and street, ciry, state, ZIP mde) /J
S oQ�/2 l/�%4iu> S i f 2/K�e�TV,v �.�c� 67G�
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land not exceeding 1(one) acre immediately (��
suROUnding 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 6J (7)
Total value (line 3 plus line 7J (8)
I hereby certify the above is true, conec�, and Sgnamre ot assemr oare signed
complete.
Verifying actbn - Sgnamre of Auditor Date signed
STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _
Lesser of 1/2 Homestead S
Valuation or 52,000
Sig re of AWit Date sig
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