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CLAIM FOR HOMESTEAD PROPERTY TAX 1 i FORM YEAR
CREDIT /STANDARD DEDUCTION HC10
State Form 5473 (R614-03)
Prescribed by the Department of Local Government Finance
INSTRUCTIONS: See reverse side for filing instructions. FILED
CERTIFICATION 'STATEMENTi:. r<><„_.:i": =`? .: W N;1,
I (We) "Fr,' 1 st. ay of March, 20_
(We) occupied as our principal place of residence the following described real property for which a Hom ax d is eb armed:
I
�(We) owned ❑ Are buying under contract COII Y AUDITOR
Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns the property or is buying under a contract.
gCONTRACT.RECORDEDT'_.,,
If buying on contract, Fee Simple owner's name
Recorder's office where contract is recorded Record number Page
1':t,:= .sur,��'is _ -- �.` u' r. X' i> rt?' fr.= �?tPROP.ERTY;OWNEDIBY.CL'AIMANT IN, OTHER 'COUNTIESP- a$..�,.r"'.`�. �" 1t• F�r..�:��'s"'�'- ,^S!�',r8."K':z
County
Tamship
Taring list ' t (ity, to , to ship)
Parcel number
al ption Is the propert,--y--,i,n
_
/5qqut�estion:
UJ,Rea1 property ❑ Mobile 4o (l.C. 61.1 -7)
If any portion of the residential structure or the land not exceeding one (1 e Nat i mediatey wmounds that suucture is used to produce income, describe the use and portion
of the property uffued to produce income.
1':t,:= .sur,��'is _ -- �.` u' r. X' i> rt?' fr.= �?tPROP.ERTY;OWNEDIBY.CL'AIMANT IN, OTHER 'COUNTIESP- a$..�,.r"'.`�. �" 1t• F�r..�:��'s"'�'- ,^S!�',r8."K':z
County Township
County Township
I hereby certify the above statements are true, correct and complete.
Siq�yture of claimant
J`
�ress (number and street, city, state, ZIP cede)
iRUSE 0* NLYASSESSO
ASSESSEDVALUE
"AT
A-�HOMESTEADMY;y'C
NON - RESIDENTIAL n
AUEAffl
j RgWOVM
j'%VALUE
Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
(1)
_•Y t`pt, '�„ec�.ta!
Other land"
'^
Total land (line 1 plus line 2)
(3)
Dwelling
(4)•%i49a!•'"
.:
Residential improvements or Annually
Assessed Mobile f Manufactured Home
Garage
(5)s
„g +: �•
•.�
Other improvements
(6)
Taal improvements (line 4 through line 6)
(T)
Total value (line 3 plus line 7)
(6)
I hereby certify the above is true, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
fsui .
� STANDARD_:DEDUCTION'ALLOWANCE
_g
20_Pay 20_
Lesser of 112 Homestead
valuation or 535.000
S
ignatu of Auditor Da77 ned