Homestead_DollahanCLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT /STANDARD DEDUCTION
State Form 5473 (R614-03)
Prescribed by the Department of Local Gmemment Finance
INSTRUCTIONS: See reverse side for riling instructions.
FORM YEAR _
HC10
ITATEMENT-:.. , =s?'c..' n. 9th ?= v.- 1::e:�'�._' s;. "?. .. -1
I (We) I certify that on t� 1 st day of March, 20
I (We)
pied as our principal place of residence the following described real property for which a Homesteads e ' ✓'Credit is hereby claimed:
❑ I (We owned ❑ Are buying under contract d (J Ty AUOtTOR
ON COON
Have a beneficial interest in the entity that is liable for the property taxes on the property and that gns the property or is buying under a contract.
'.;`.` s'✓= C^&'' c�s+ '+s"ta- w,Fy}�;'"is_i"'"a,`1�':i ONTRACT.'RECORDED -aey .t ,i �'_ „',,s n7
If buying on contract. Fee Simple owners name i
Recorder's office where contract is recorded Record number Page
-
'cam— mo_,w�c_+ -arx ROPERTY. DESCRIPTION '�'t- •'++._� ?s�!''tr�o-,'- �....'•�. �i sni4:
County
Township
County Tmnship
T m dirt' t (' , town, to -
t
Addr (number end sues city, state, ZIP code)
® 1
e`� '-TRUE TAX�tr� ASSESSED VALUE HOMESTEAD ON'- RESIDENTIAL�`r.
ASSESSOR USE ONLY p'
Pncel number
/(D D _�
Legal cdpUon
(11
Is the property' question:
`' �`
surrounding residential improvements.
Real property [] Mobile Hone (I.C. 6-1.1-7)
If any portion of the residential aW cture w the land not exceeding one (1) awe
of the prpp to produce irx:ome.
/JJ
at imme iate surrounds that cture is used to produce income. describe the use and portion
YY
Otherland
cfG
_.
�"`ti1c P, R P.ERTY,OWN ED 'BY CLAIMANT IIJ'OTNER'COUIJTIES'x:��
County
Township
County Tmnship
I hereby certify the above statements are true, cored and complete.
Signature of claimant
Addr (number end sues city, state, ZIP code)
® 1
e`� '-TRUE TAX�tr� ASSESSED VALUE HOMESTEAD ON'- RESIDENTIAL�`r.
ASSESSOR USE ONLY p'
,y yVAL6E AT.- 100 %_OFs SUE v” i y
.,.rr«i'.i....�. __.. az3 �:. ,. a. ral+.s..VALUE
Land not exceeding 1 (one) acre immediately
(11
`' �`
surrounding residential improvements.
�
, &+tt„
Otherland
(2)
r,•-
����?
''FARW '
Total land (line 1 plus line 2)
(3)
Dwelling
(4)
(Residential improvements or Annually
Assessed Mobile I Manufactured Home
Garage
(5)
Other improvements
(6)
=_-
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(6)
1 hereby certify the above is true, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
WV��2i0ar_v�4Pa?a`y
20_ -
Lesser of 1r2 Homestead
Valuation or 535.000 S
Signature of Auditor Date signed