Homestead_BlytheCLAIM*OR HOMESTEAD PROPERTY TAX FORM YEAR
CREDIT /STANDARD DEDUCTION HC10
State Form 5473 (R614-03)
Prescribed by the Department of Local Government Finance
INSTRUCTIONS: See reverse side for riling instnxtions. T" y
I(We) t-J�kA - OC�!X t, IA- A. 12 t IV N - certify that on rttapo 20_
our principal place of residence the folio described party for which a Homestead Property axCr I suclaimed:
I (We) occupied as o llodg�les, ad real pro v%
Ej I (We) owned ❑ Are buying under contract
Save a beneficial interest in the entity that is liable for the property taxes on the property and that owns the proferty ?or s�linguiVna contract.
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If buying on contract, Fee Simple owners name
Recorders office where contract is recorded Record number Page
J
i"IskOPERTX.DESCRIPTION
County
Township
I hereby certify the above statements are true, correct and complete.
County
Township
Taring district (city, town, township)
Eprattl number
n110 —
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property in question:
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❑ Real property ❑ Mobile Home (I.C. 6-1.1-7)
If any portion of the residential structure or the land not exceed one (l) acre that I-0
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lately Rumounds that structure is used to produce income, describe the use and portion
of the property utilized to pnxtuoer income.
M W,7PROPERTY,-OwNEij!BY.CLAiMANT;lk'OTHER,COUNTIES��,:,���rt«.,-,:EZ�-,-,,cr N--g-t.�s
County Township
County
Township
I hereby certify the above statements are true, correct and complete.
Signature of claimant
W(number and street, city, state, ZIP code)
L E�
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WWI1'
TRUET
Cis't6VA
HOMESTEAD
M
�NO WRESIDE NTIAL -,I-P,
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alt �
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Land not exceeding I (one) acre immediately
Signature of Auditor
C�2 , 1"; -2- 1W
W- 00-
surrounding residential Improvements.
1
Other land
(2)
Total land (line 1 plus line 2)
(3)
Dwelling
(4)
-$W4,
Residential Improvements or Annually
Assessed Mobile I Manufactured Home
Garage
(5)
V1 improvements
(6)
.et
r
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(8)
1 hereby certify the above is true, correct and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
STANDARD, DEDUCTION"ALLOWANCE
20_Pay2O_
Lesser of 1/2 Homestead
Valuation or MAD
S
Signature of Auditor
Date signed7
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