Homestead_SimmonsFORM HC 10 1979 To Be Fi1M in Onfi icate
Prewrided By Slate Board of Tax Commissioners
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT FOR YEAR 19 $(
SEE BACK FO�Rp FILING INSTRUCTIONS 016 - D/V 0 O a
xt f certify that on the 1st day of
March, 19--g—L, I, (We) occupied a our principal place of residence0hAol lowing 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 n
Property Description in -County q O'�.� Township
Taxing District (City, Tom}: fl a_ 1 ,
Parcel Number or legal description shown on tax atement:
If buying on contract: Owners name 1'ft simple owner)
Contract recorded in Recorders Office - Record No. Page 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: County Township
„hereby certify the above statement is true, correct and complete.
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 T
Total Land -FILED
Residential Improvements'
mprovements MA`( 11 1� Dwell 9
)AS AVp1SOR at
Other Improvements
TkImprovements - Line (6) plus (7) equals (8)
it certify the above is true. correct, and complete.
Signature of Assessor
True Cash Assessed
Value Valuation
(1) 13x0 c
(2)
(3) /3ao
(4)
(5)
(6)
(7)
(8)
ION BY AUDITOR -
3c
X/Z/0
Homestead
Valuation
ay 5 o
Oate
Date: