Homestead_Wright (15)FOHM HL 10 1979
PrescriDed 9y Staie 9wr0 af ta. Commissianerz
io Be FileO in Duplicate
- CLAIM FOR HOMESTEAO PROPERTY TAX CRE�IT FOR YEAR 19�� ✓
S E BACK FOR FILING INSTRUCTIONS p�c�_ p 3333 -��
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�(We) 'r°�' � t �' '"� certify that on the 1st day of
�Aarch, 19 7 I, (We) occupied as our principal place of residence t 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 interest,in the taxpayer
Property Description in
Taxing District (City, Town, Township): ✓
Parcel Number
v � Township
or legal description shown on tax statement:
`� YZ-Q'7�—P . /j /.�.,., n i, � �
If buying on contract: Owners name ��� simple owner�
Contract recorded in Recorders Office - Record No. Paoe
If any portion of the residential structure or ihe 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
� reby rtif the above statement is true, correct and complete.
' , % , / �� - - � � �
�gna...re ' Sneet Atl ress Ciry. State nG 2' �COtle
' Individual either owns or is buying under a contract that provides he is to pay ihe 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
ootal Land � � � �° �
Residential Improvements ,
,j�i 3 i979 Dwel�l�n9
Garage
� �, ��(�u�2�Total
Other Improvements � AUDITOR
T�'�' Improvemenis - Line (6) plus p) equals (8)
F�by certify the above is �e, correct. and complete.
Signamre ol Asuswr
Approved
True Cash
Value
(�) /��o
(2) — ° —
(3) /��O
,�
Assessed Homestead
Valuation Valuation
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