Homestead_Gray (2)t HC 10 1979
Scribed By State Board of Tax Commissioners
To Be Filed in Ouplicare
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT FOR YEAR i9j-
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/ ` 4
SEE BAC�K FOR FILING INSTRUCTIONS
016 -
001/100- OZ
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certify .that on
the ist day of
rch, 19 , I, (We) occupied
as oAr priobioal place of residence
the following described real
operty for which a Homestead
Property Tax Credit is hereby being
claimed:
(We) ® owned
are buying under contract
have a beneficial interest in the taxpayer .
operty Description in Z'%i , County
xing District (City, Town, Township) :
Township
rcel Plumber or legal description shown on tax statement:
buying on contract: Owners name (fee simple owner) Pte„
Contract recorded in Recorder's office - Record No. Page
any portion of the residential structure or the land, not exceeding one (1) acre that
mediately surrounds that structure is used to produce income, describe the use and portion of
.e property utilized to produce income
f other counties in which individual owns or is buying real property: County Township
h� certify the above statement is true, correct and complete. y/766o
*Signature Street Address City, State CAhd Zip Code
*Individual either owns or. is buying uner a contract that provides he is to pay the
property, taxes on the residence, or has a beneficial interest in the taxpayer.
- FOR ASSESSOR IS USE ONLY -
True Cash
Value
-d not exceeding 1 (one) acre immediately
xrourding residential improvements (1) 9S-0
her Land (2)
)tal Land
!sidential Improvements
her Improvements
improvements - Line (6) plus
h,,f certify the above is true,
i. \ -
(3) S V
Dwelling (4)
Garage (5)
Total (6)
(7)
(7) equals (8) (8)
correct, and eonplete.
- ACTION-BY AUDITnR -
Date