Homestead_ByrumFORM HC 10 1979. '
Prescribed By Slate Board of Tax Commissioners
To Be Filed in Duplicate
O I to — bo 1 ` Q —DO
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT FOR YEAR 19� z�
SEE BACK FOR FILING INSTRUCTIONS
Ne) certify that on the 1st day of
tv rch, 19 I, (We) occupied as our principal place of residence the following described real property for
which a�Ho�mestead Property Tax Credit is hereby being claimed:
I, (We) frowned
❑ are buying under contract
❑ have a beneficial interest i the taxpayer
(f� 1
Property Description in County Township.
Taxing District (City, Town, Township): 1 r 4—,.
Parcel Number
If buying on contract: Owners name Itee simple
or legal descrt')tion shown on tax statement:
Contract recorded in Recorders Office - Record No. S Page 440
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'lto p gduce= income
Any other counties in which individual owns or is buying real property: County 1)1M (;Township
certify the above statement is true, correct and complete.
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 (one) acre immediately
surrounding residential improvements (1)
Other Land (2)
Total Land (3)
Residential Improvements Dwelling (4)
Garage (5)
Total (6)
Other Improvements (7)
Tr Tnprovements - Line (6) plus (7) equals (8) (8)
111YPILy certify the above is true. correct, and complete.
Assessed Homestead
Valuation Valuation
Signature of Assessor Oate
/ny _- - , ,' A , -� JACTION BY AUDITOR -
Approved: �'� '' ' '-"1"""' Date: