Homestead_SetseryRx)7
CLAIM FOR HOMESTEAD PROPERTY TAX FORM
; CREDIT /STANDARD DEDUCTION Hclo
, l • State Form 5473 (R215-92)
INSTRUCTIONS: See reverse side for riling instructions.
YEAR
%CER FICATION STATEMENT;
I (We) certify that on t La hh:xppaa���gg��.��- -" I (We) occupied as o r rincipal ptace of residence the following described real property for which a Homestead Property T r is y�nD
1'- We owned
❑ Are buying under contract
�I
Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns the property or is Mg yn2r % firact.
- _ -_ CONTRACT RECORDED,.-.
It buying on contract. Fee Simple owner's name ;r I'%�'
GIBSON C ^(RfT'i AUDITOR
Recorder's office where contract is recorded Record number Page
PROPERTYDESCRIPTI - "" ' °_' -. .s - -.. •'<... v ..
County
Township
Taxing disr T to f
r I umber
- Q C3 U
Legal desorption
If any pWion 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.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES - - -
County Township
County Township
HOMESTEADS
VALUE
NON - RESIDENTIAL
VALUE
certify the above statements are true, correct and complete.
Signature f claimant
ahereby
number and street. city, state. ZIP code)
I
ASSESSOR USE ONLY -
TRUE TAX
VALUE
ASSESSED
VALUE
HOMESTEADS
VALUE
NON - RESIDENTIAL
VALUE
Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
(1)
- .
Other land
(2)
- -
Total land (line I plus line 2)
(3)
Residential improvements
Dwelling
(4)
..
Garage
(5)
Other improvements
(6)
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plrs line 7)
(6)
I hereby certify the above is true, correct, and
complete.
Signature of Assessor
Date signed
Verifying action - Signature of Auditor
Date signed
- STANDARD DEDUCTION ALLOWANCE—.
19_Pay 19_
Lesser of 112 Homestead
Valuation or 52,000
$
Signature of Auditor
Date signed