Homestead_KochCLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT /STANDARD DEDUCTION
� r State Form 5473 (R2 15-92) -
B 6
INSTRUCTIONS: See reverse side for filing instructions.
FORM
HC10
YEAR
I I/ CERTIFICATION STATEMENT
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1 (We) C� �P certify that on the 1 st day of March, 19_
1 (We) occupied as our principifl place of residence the following described real property for which a Homestead Property Tax Ctedh C ]aimed:
❑ I (we) owned ❑ Are buying under contract ���111 -� ®(
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❑ Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns th r�s a con tract.
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CONTRACT RECORDED
If buying on com2ct, Fee Simple owners name
Recorders office where contract is recorded
R r C�t,;TY A" 1 Page
PROPERTY DESCRIPTION
County
Towns -
Taxing tlist' rJry, t�//jy,_l1rtownshrp)
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lA
Parcel number
Legal description
C91a— 0/9 — '00
If any portion of the residential structure or the land not exceedmg one (1) acre that immediately surrounds that structure is used to produce income, dewribe the use and portion of
the property utilized to produce income.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
County
Township
County
Township
Signature f aimant
iereby certify the above statements are true, correct and complete.
C
Address (number and street, city, state, ZIP code)
31 ' ao.,•,d C
v I e fL
ASSESSOR USE ONLY
TRUE TAX
ASSESSED
HOMESTEAD
NON- RESIDENTIAL
VALUE
VALUE
VALUE
VALUE
Land not exceeding 1 (one) acre immediately
(1)
surrounding residential improvements.
Otherland
(2)
Total land (line 1 plus line 2)
(3)
Dwelling
(4)
Residential improvements
Garage
(5)
Other improvements
(6)
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(8)
1 hereby certify the above is true, correct, and
Signature of Assesor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
STANDARD DEDUCTION ALLOWANCE
19_ Pay 19
Lesser /2 omestead
5
V 0 2 00
Signature of Auditor
Date signed
- o
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