Homestead_SpitlerFORM HC 10 1979 To Be Fled in Oupliwte
Prewrilied By State Board of Tax Commissioners '
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT FOR YEAR 19Z_
SEE BACK FOR FILING INSTRUCTIONS O _C)10yS -_00
(We) F. certify that on the 1st day of
vtarch, 19 I, (We) Aupied as our pr cipal 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 int rest in the taxpayer
Property Description in County Township
Taxing District (City, Town, Township):
Parcel Number F or le at description show on tax statement:
If buying on contract: Owners name )tee simple owner)
Contract recorded in Recorders Office - Record No. Pace
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:
'Signature
certify the above statement is true, correct and complete.
m
510
Street Address
0
County Township
and Zip Code 0
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
True Cash
Value
(1) 10df)
(2) —0-
(3) 60-0
J.
Approved:_
N�
Assessed Homestead
Valuation Valuation
a a-o
0
6 -/- 79
Date
Date: