HomeMy WebLinkAboutHomestead_LuebkeFORM HC Ig W9 To Be Filed in Duplicate
Prescribed By State Board of Tax Commissioners
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT FOR YEAR 19
SEE BACK FOR FILING INSTRUCTIONS 01b _ 00(acrl _01D
I, (We) 17-- certify that on the 1st day of
March, 19W I, (We) occupied as our principal place of residence the following described real property for
which a Homestead Property Tax Credit is hereby being claimed:
I, (We) ® owned
❑ are buying under contract
❑ have a beneficial interest in the taxpayer
Property Description in County
Township
Taxing District (City, Town, Township): v a
Parcel Number or legal description shown on tax statement:
ez_4r 1-- d-t9Y'
/ S -z- 8 036f1•
If buying on contract: Owners name Ifea simple owne)
Contract recorded in Recorders Office - Record
If any portion of the residential structure or the land, not exceeding one (1) acre that immediately surrounds that
structure is used to produce income, describe the use and portion of the property utilized to produce income
Any other counties in which individual owns or is buying real property:
"hereby certify the above statement is true, correct and complete
-Signature
Street Address
E'A
County Township
City. State and Zip Cone
Individual either owns or is buying under a contract that provides he is to pay the property taxes
on the residence, or has a beneficial interest in the taxpayer.
- FOR ASSESSOR'S USE ONLY -
Land not exceeding 1 (one) acre immediately
surrounding residential improvements
Other Land
Total Land
Residential Improvements
FILED
MAR 17 1Gffl9eg
P Improvements O AUDITOR
1u I Improvements - Line (6) plus (7) equals (8)
1 hereby certify the above is true. correct. and complete.
Signature of Assessor
(4)
(s)
(6)
(7)
(8)
- ACTION BY AUDITOR -
Homestead
Valuation
3 -.a- $I
oa,e
True Cash
Assessed
Value
Valuation
(1)
77o
(2)
— bo -�✓
(3)
'7
(4)
(s)
(6)
(7)
(8)
- ACTION BY AUDITOR -
Homestead
Valuation
3 -.a- $I
oa,e