Homestead_ClarkCLAIM FOR HOMESTEAD PROPERTY 'TAX FORM YEAR
t CREDIT /STANDARD DEDUCTION
HC70
Stale Form 5473 (R6 /1-03)
Prescribed by the Department of Local Government Finance
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INSTRUCTIONS: See reverse side for tiling instructions. I, �L t
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CERTIF.IC_ Ti0_NSTATEMENTr.-r .syy -o+,s
I We w �eRify that on the tst/day of Mar 20_
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1 (VJe) o ad as our principal place of residence the following described real property for which a Homesfe d Property Tax.Credifis.h�0reby claimed:
�i�,
❑ I (We owned ❑ Are buying under contract "aSON CCli st i v It )
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.
.......-9.z�'�vt
It buying on contract. Fee Simple owner's name
Recorders office where contract is recorded Record number Page
--W- -�s� '�tx.s: --0-r- err:: PROP.ERTY,OWNEDjBY;CLAIMANT:IN: OTHER "COUNTIES`.`_, aiy,,-' trgg?ya
County
Township
County Township
Ta ing s riot ('ty, wn, tow ip
Parcel mbe
D/ GOD O _�
g U tion
Is the prop estion:
at properO ❑ Mobile Horno (I.C. 6-1.1 -7)
If any portion of the residential structure or the Land not exceeding one
of the property utif¢ed to produce income.
cre Nat immedialey wrtounds that s re is used to produce income, describe the use and portion
--W- -�s� '�tx.s: --0-r- err:: PROP.ERTY,OWNEDjBY;CLAIMANT:IN: OTHER "COUNTIES`.`_, aiy,,-' trgg?ya
County
Township
County Township
I hereby certify the above statements are true, coved and complete.
Sig re claimant
Address (number and street, city; state, ZIP code)
65111 /Lo,-L
OFTfVOVALUE
.- s.,.i•+.... ,ss„
AaSS�350RNLjVAL.U_E'tF.,o
',,..•�`'-
N'•sON�RESIOENTiIA€
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OFTfVOVALUE
.- s.,.i•+.... ,ss„
.�,-.. ....,..
mrdx`VALUE..;?�s3y, ,n
Land not exceeding 1 (one) acre immediately
O
surrounding residential improvements.
Other land
(2)
Total land (line 1 plus line 2)
(3)
Dwelling
(4)
„A F,yyy w
Residential Improvements or Annually
Assessed Mobile/ Manufactured Home
Garage
� -r ��
`'�,� �s
p
(6)
'
m'it.nL' r
Other improvements
(6)
;;�v -fir '
-.Sx "F,
Total improvements (line 4 through line 6)
(T)
Total value (line 3 plus line 7)
(6)
I hereby certify the above is true, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed