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Pr¢SC�i�eO By Slal¢ BoarG 01 iav Commi55foners . /�,
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CLAIM FOR HOmESTEAU PROPERTY TAX CREDIT FOR YEAR 19� ✓
SEE BACK FOR FILING INSTRUCTIONS ✓0/9�033e7s-op
�-�') Ga� certify ihai on the tst day of
�Vi�.,,n, 19��, I, e) occupied as our principal place of residence the following de=_cribed real properiy for
which a Hom�siead Property Tax Credit is hereby being claimed:
I, (We) L�" owned
❑ are buying under contract
❑ have a beneficial interesi in the taxpayer
Property Description
Taxing District (City, Town, Township):
Parcei Number
—u•�:� ����
� ��-}L�_�a�
If buying on contract Owners name ��ee s+mo�e o.��n
nty
Township
or legal description shown on tax statemen�
��1 � n., �!
��%�:'� 0-� :Contract recorded in Recorders Office - Record No
If any portion oi ihe resideniial structure or ihe land, noi exceeding one (1) acre that immediately surrounds that
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siructure is�tised=TO produce�income, describe the use and portion of the property utilized to produce income
[�itij�i(}:: v
Any other counties in which individual owns or is buying real property:
certify the above statement is true, correct and complete
AOaress
County Township
i.�ry. a�a�e ano uo �.we
Individual either owns or is buying under a coniract ihat provides he is to pay the property taxes
on the residence, or has a beneficial interest in the taxpayer.
- FOR ASSESSOR'S USE ONLY -
Land not exceeding 1(one) acre immediately
surrounding residential improvements
Other Land
Total Land
Resideniial Improvements
D�velling
Garage
Total
True Cash
Value
(�)
(2)
(3)
(��
(5)
(6)
Other �mprovements (�l
Totai�rovements - Line (6) pius (7) equals (8) (8)
I hereoy ceriify the above is true, correct, and complete.
Signzwre ol Assessor
- ACTION BY AUDITOR -
A.pproved: �ji�q—'!"��'
Assessed
Valuation
n.,�.
Homestead
Valuation
Date:.—�_ -�-�� �--