HomeMy WebLinkAboutHomestead_BlackFORM HC 10 1979
Prescribed By State Board of Tax Commissioners
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT FOR YEAR 19 7
SEE BACK FOR FILING INSTRUCTIONS
To Be Filed in Oupliole
D /(o- Door? 2- oa
�(We)a" 1� yy c c - ' �-� k %certify that on the 1st day of
arch, (We) occupied as our principal p ce 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 fst in the
A r.
Property Description
Taxing District (City, Town, Township): v a—
Parcel Number
If buying on contract: Owners name
my Township
or xlegal descriptiow shown on tax statement:
Contract recorded in Recorders Office - Record No
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 true, correct and complete.
Andrew City, State and Z� Code
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 exceeding 1 j� e) cre 1 m edly
surrounding residentialEprJeme (1)
Other Land (2) —0—
Total Land (3) —�--0--0
Residential Improvemen' r welling (4)
Garage (5)
AUDITOR
Total (6)
Other Improvements (7)
Tr(�' Improvements - Line (6) plus (7) equals (8) (8)
1 !0by certify the abovflis true. correct, and complete.
Signature of Assessor
Approved
Assessed
Valuation
i7o
-19-
/70
Homestead
Valuation
Date
Date:
l G
7