Homestead_BrubakerCLAIM FOR HOMESTEAD PROPERTY TAX t L FORM_ YEAR
CREDIT /STANDARD DEDUCTION THCtDi
State Fond 5173 ( 11-03) 1_
De
Prescribed by the Department of Local Government Finance �yl
INSTRUCTIONS: See reverse side for filing instructions. _ MAR O U 2004
� ' �'- -- 3 CERTIF STATEMENTi- st`st ` fl, `sue
r� ,certify t on -t(ie =1st dWof March, 20
(Wey pied as our principal place of residence the toll described real property for which�a HornesteaA `Property Tmi Credit is hereby claimed:
.LI,d, /I (W owned ❑ Are buying under contract
Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns the property or is buying under a contract.
ti.._1'iv4f5/u,Y °.'� •it'+�.l.Li.T J' l ,36, ^d..n� -in - ._ -_.w
ONTRACT'RECORDEDft' ��l; �, r#'' �r: �� "- i'y�,�.�R,�,a-�4- .s'�y�,�-%s"
If buying on contract. Fee Simple owners name
Recorders office where contract is recorded Record number Page
— � "- Pa sr''.`�4+Fx. %"<` •
; _-
• `'„ nP ,ROP.ERTY.DEBCRIP.T10N4��_:�`�- `a `•'•.' < tom.
"*
County
Township
County
Tadn riot (" , t , township)
Parcel number p
0110-0011q- ct
Legal description
Is the property in question:
r
o/
d eat property Mobila Home ILC. 6-1.1 -7)
if any portion of the residential structure or the land not exceeding one (1 j acre that immediate surrounds that sWcture is used to produce income, describe the use and portion
of the property utilized to produce income.
�- -:. -_ ROP.ERTY;OWNED,BY CLAIMANT. INOTHER`COUNTIE §€'�°�,,°,�_,`
„: 'S
County
Towship
County
Township
I hereby certify the above statements are We, correct and complete.
sign to of tmant
n ^
Uv
Address (number and street, city, state, ZIP code)
I
ONLY ?j'bTRUETAXr
ASSESSED VALUEHOMESTEAD•'
"NON ESIDENTIALfy:.
,AT 100 %OFyTfV j
B!�VALUE
a.S"t' VALUE L`t%: "y”(
Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
(1)
�•_µµ���
Other land
(2)
Trial land (line 1 plus line 2)
(3)
Dwelling
(4)ac)z-
Nq kit s
Residential improvements or Annually
Assessed Mobile / Manufactured Home
Garage
5
_
Other improvements
(6)
-
Total improvements (line 4 through line 6)
(T)
Total value (line 3 plus line 7)
(6)
1 hereby certify the above is We, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
,•s- -W�'-`x�'STANDARD DEDUCTI0N ALL OWANCEt'"
IV 20 _ Pay 20 _
Lesser of 1/2 Homestead
T
valuation or 535.000
Signature of Auditor Date signed