Homestead_BrockFORM HC 10 1979
Prescribed By State Board of Tax Commissioners —
To Be Filed in Duplicate
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT FOR YEAR / l�
SEE BACK FOR FILING INSTRUCTIONS (0/r0 — OO /Q/- OQ
L®(We) -r �_ cl c.r * �
March, 19 I, (W661occupiedgs our pr
which a Homestead Property Tax Credit is
I, (We) ❑ owned
❑ are buying under contract
❑ have a beneficial inter t inayer
Property Description in
Taxing District (City, Town, Township):
Parcel Number
If buying on contract: Owners
Contract recorded in Recorders Office - Record
,.07-f certify that on the 1st day of
ace of residence the following described real property for
being claimed:
my
C
i
or legal description
Township
on tax statement:
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.
Address
and
j0
_7/7!60
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 -
Land not exceeding 1 (one) acre im isyggly
surrounding residential improvement U
Other Land
— Total Land
5 1979
True Cash Assessed Homestead
Value Valuation Valuation
,
i r
.-iesioeniiai improTemenis
/ / �
cJ —off —
Daze
Approved: Y` Date: 4 —S ��