Homestead_NorrickFORM MC 10 19i9
Prescribed By State Board of Tax Commissioners
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT FOR YEAR 192.
To Be Film in Duplicate
0/6 — 00 t%7/. oz)
_10(We) VV15L4-tca- A certify that on the 1st day of
March, 19 - ", 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
fire buying under contract
❑, have a beneficial in r st in the taxpayer
Property Description in County
/,
Township
Taxing District (City, Town, Township):
Parcel Number or legal description sho n on tax statement:
If buying on contract: Owners name 0- simple owner
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:
I hereby certify the above statement is true, correct and complete
®Ll
Address
County Township
mod_ (�- X7660
City. Slate and Zip Cane
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 L 1E
ling
Garage
JUL 071979 Total
Other Improvements
T tal,Improvements - Line pl
I_by certify the abov tr t'
Signature of Assessor
True Cash Assessed Homestead
Value Valuation Valuation
(1) —l70
(2) —0—
(3) Z-"
(a) 3 0
(s)
(6) x
(7) a J00 a
(s) 7 3
- ACTION BY AUDITOR -
—6—
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1b0
C
Approved: e. /�/ • ��> Date:_ %oZZ %9