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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT /STANDARD DEDUCTION
` State Form 5473 (R5 110-01)
Prescribed by the Department of Local Government Finance
INSTRUCTIONS: See reverse side for tiling instructions.
FORM YEAR
HC10
(We) - - �l. y /"i^-�.1� certify that on the MAY st day 60f gig? 20
I (We) occupied a ur principal place of residence the following described real property for which a Homestead Property Tax Cr .t is hereby da' ed-
❑ I (We) owned ❑ Are buying under contract
Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns the grope- eris liri}9lig\inB60101T/>?ract.
iK�CONTRACT'.RECORDEDssar_._
If buying on contract. Fee Simple owner's name
Recorder's office where contract is recorded Record number Page
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ASSE k'-,-, SE ONLY- i .
- r' iPROP, ERT, Y, DESCRIP, TIOWfs'- `4`-'��'.?f'.^�iA"rc13'i'y,3 %<
Township
Township
hereby certify the above statements are true, coned and complete.
Taring district town I ' )
Parcel number
al descri lion
3%..,?5n #VALUE �
Is the pmpe in question:
O /�— 9 -d
�,tt
II
eal property ❑ Mobile ome (LC. 6f. f -7).
If any portion of the residential sWcture or the land not exceeding one (1) a"rephat
ikimAd ' r08�at sWGure is used to produce income, describe the use and portion
Of the property utilized to produce income.
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County
Township
County Township
hereby certify the above statements are true, coned and complete.
i n re of claimant
re mbf aM�streeL � ,sta�e ZlP codely ��1 / T,t / Y76,&d
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- MAY S
p TRU6TAAX '
-
ASSESSED VALUE
1. -
A�� -HOME
S ucmtiau -.
r}•, ;:y,'�gd -2. 1;K, . ^T
' VALUE
ATz100%e.OF�'TTV
3%..,?5n #VALUE �
{�}3�'1! � VALUE .,>r:
FS..,y_-afi;t0RR „_
�,tt
,'a�`
Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
~
Other land
(2)
Total land (line 1 plus line 2)
(3)
Dwelling
(4)
' �a£.�rC F 2
Residential improvements
�^ wiz-.
Garage
(S)i
<-
rfo, a�.�„��,
� '� �1
Other improvements
(6)
r �?: �� z
% -: m
Total improvements (line 4 through line 6)
(7)
Total value (fine 3 plus line 7)
(S)
I hereby certify the above is We, corned, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
20_Pay 20_
Lesser of 1/2 Homestead
Valuation or $6,000
Dale s
-O 6