Homestead_WardO
w�n Hc io �s�
PrescriUeE By State BoarE af TaM tommissioners
CLAIM FOR HOMESTEAU PROPERTY TAX CREOIT FOR YEAR 19��
Ta & FileE in WD�iwte
_�
SEE BACK FOR FILING INSTRUCTIONS p�q_ 03078-00
(We) certify that on the 1st day of
� arch, 19� I, W 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) C�owned
❑ are buying under contract
❑ have a beneficial inte,r�e/st �in the taxpayer
Property Description in .�4–Ud–«.-.-+ County `P��ti= Township
Taxing District (City, Town, Township): `�'u�+�� �+*�-.��J �
Parcel Number or legal description shown on tax statement:
`Qc.e-0..ol.�.cs�.. � P �.� 5
,
If buying Ofl contract: Owners name ��� simo�e owner�
Contract recorded in Recorders Office - Record No. Page
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: County ' Township
� hereby certify the above statement is tr , correct and complete.
� � � �
' ig e e i Sireec AOaress Cily. tate ane Zip CoC¢
' 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
Value
Land not 9xceeding 1(onp��m edia� �
surroundin residential im e t (�) �/ ��
Other Land
Total Land .i'1:. 12 1979
Residential Improvements /%� we ling
��� i
AUDITOPSarage
Total
Olher Improvements
Tot � Improvements - Line (6) plus (7) equals (8)
I�oy certify the above is true. correct. and compiete.
ASSP550r
(2) �
(3) a/ PD
(4) 5 0
- ACTION BY AUDITOR -
Assessed
Valuation
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1.3ei'
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Homestead
Valuation
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