Homestead_BurkhartFORM HC 10 1879
prescribed By State Board of Tax Commissioners
To Be Filed in Duplicate
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT FOR YEAR 19 8 3
SEE BACK FOR FILING INSTRUCTIONS 016_ 00/3S' 00
.<V7(We) / '/2 ^-�, �"--� e` ^' / 'C-L - certify that on the 1st day of
March, 19---U I, (We) occupied as our principal place of residence the following described real property for
which a Homestead Property Tax Credit is hereby being claimed:
I, (We) Downed
❑ are buying under contract
❑ have a beneficial interest ifln/th�e taxpayer
Property Description in �'�`°--"^ County
Township
Taxing District (City, Town, Township): tj
Parcel Number or legal description shown on tax statement:
a
If buying on contract: Owners name (fee simple owner)
Contract recorded in Recorders Office - Record
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
other counties in which individual owns or is buying real property: County
Wreby certify the above statement is true, correct and complete.
J
Township
and
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 immediately
surrounding residential improvements
Other Land
Total Land
Residential Improvements �[[�$$ elling
image
983 Total
Other�mprovements P'I!� ( t
T�.mprovements Line ,p�fis r
I hereby certify the above .'is true. w tda complete.
signature of Assessor
True Cash
Value
(1) so 0
(2) —
(3) S o 0
(4)8
(5) —
Assessed
Valuation
Homestead
Valuation
/d
- jjjjj/
- ACTION BY AUDITOR -
Date
Approved: Date: