Homestead_Hazelwood (2)CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
Slate Form 5473 (R6 / 403)
Prescribed by the Department of Local Goverment Futartce
INSTRUCTIONS: See reverse iii b fift raftc i m
FORM `W YEAR
HC10
FILE
I (We) V ' W certify t at on the 1st ifey of March, 20_
(We) occupied as our principal place o reside the following described real property (o i a Homestead-PS�a r Tax Credit is hereby claimed:
❑ 1 (We) owned ❑ Are buying under contract RR O O r�%/
h' property P P nY ovSltlSt�iBp POUNTY �tyP90R
Have a beneficial interest in the entity that is liable for the taxes on the roe and that ro errttYY T Is u m under a contract.
'RECORDEDNTR/CT.
If buying on contract, Fee Simple owner's name
Recorders office where contract is recorded Record number Page
�.i•?Sz ��-" 3- �f�-' ��", P,ROP.ERTKOWNED.BYCL'AIMANT,IN: OTHER "COUtJT1ES �`�,,�. •�,�:"�'�:�v".'�!f/ ^gam;:
County Township
County
Township
Taring district (city w hiP)
Par�ai y�be'D I �g 3
Legal descrip o/
9town
eBl 'nROal�propeM ❑ Mobile Homo
If any porttionon of the residential structure or the land not exceeding one (1) acre that immediat surrounds feWature is used to produce income, describe the use and portion
of the property utilized to produce income.
�.i•?Sz ��-" 3- �f�-' ��", P,ROP.ERTKOWNED.BYCL'AIMANT,IN: OTHER "COUtJT1ES �`�,,�. •�,�:"�'�:�v".'�!f/ ^gam;:
County Township
County Township
hereby certify, the above statements are true, correct and complete.
SM
Claimant
dress (number aM street, city, orate, ZIP code)
�11T�100 %'OFD "T.TV
- - — I U . -
"'3i
-ei>R ASSESSORUSE ONLY + �.-
TRUE-TAX' '��g
ASSESSED VALUE
HOMESTEAD`-
r
'� NON,�RESIOENTIAL ,,.�
-
MjVA_LUEr
�11T�100 %'OFD "T.TV
r
Land not exceeding 1 (one) acre immediately
A
surrounding residential improvements.
Other land
(2)
.. sx
;s {���,�y}'
Total land (fine 1 plus line 2)
(3)
Dwelling
(4)
♦ 4i.esr rJ- r1' a, ate- ..
yr r- r4 �`t 7`a?b>•a
(Residential Improvements or Annually
Aasassed MobOe /Marwfacbrred Home
Garage
(6)
_�
,s:tn
Other improvements
(6)
k" #z
Total improvements (line 4 through line 6)
(T)
Total value (line 3 plus line 7)
(S)
1 hereby certify the above is true, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed