Homestead_DeppeCLAIM FOR HOMESTEAD PROPERTY TAX FORM
CREDIT /STANDARD DEDUCTION Hc10
State Forth 5473 (8014-03)
Prssalbed by the Department of Loll Gwemment Finance
IN ,"UC710NS: See rurda7 d* fkrZft irmtrudmw
I (We) a s certify that on the lstAofrgf Ta�5h9920�,�__n
(We pled as our principal place of residence the following described alp party for which a Homestead Property Tax Credit is hereby�"am(ed:
I (We) 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)rrLs,buyiaqFunder a contract.
YEAR
a zCONTRACT .'RECORDED
If buying on contract. Fee Simple owners name
Recorders office where contract is recorded Record number Page
,•�'.- ;a..�� P.RDPERT.Y.DESCR-
Nom., -r�asi :'�. ��r n • —.ys •sus »--.
C Tmmship
Tali
dis
'
(Ci4" f , to
A/ONTTV
VALU.VUE�
•t
f 3'µVALUE "Fr i
Land not exceeding 1 (one) acre immediately
L al d ipdon,
Is the property in qus
eat
rty ❑ Mobile Hone (I.C. 61.1 -7)
odicn of the residential sW ralire w the land n exceeding one (1' a e Nat immediataty wrrounds that structure is used b produce income, describe the use and portion
of the a ty utituad to produce income.
County 7 Toxnship
I hereby certify the above statements are true, correct and complete. S' 01 ai ant
street, city, state,
x Ai S'sS,E5'S. S U S E N LN
TRUE TAX t•
'ASSESSED .VALUE
HO:MESTE EDS
O- RESDNTAL
aO0R " &?O6 , r
-,�.•y
A/ONTTV
VALU.VUE�
•t
f 3'µVALUE "Fr i
Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
Other land
(2)
Total land (line I plus line 2)
(3)
Dwelling
(4)
Residential Improvements or Annually
Astaessed Mobile / Manufachued Home
Garage
MIN
Other improvements
(6)
i✓��
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(6)
I hereby certify the above is We, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
20_Pay 20_
Lesser of 112 Homestead