Homestead_Willis (9)CLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR {
CREDIT/STANDARD DEDUCTION HCto
State Form 5473 (R5110 -01)
Prescribed by the Department of Local Government Finance
INSTRUCTIONS: See reverse side for filing instructions,
'CERTIFICATION STATEMENT
I (We) certify that onothCe Lll� o4m, 20
1 (We) occupied as our principy place of residence the following described real property for which a Homestead Tax,, Credit is hereby daimed:
e
❑ 1 (We) owned ❑ Are buying under contract IL)
GI
Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns the p"llimpol r16-4
A."
CONTRACTAECORDED1
I buying on contract. Fee Simple owners name
Recorder's office where contract is recorded Record number Page
r-uf�v it
PROPERTY. DESC RIPTION
Township
County
Township
I hereby certify the above statements are true, correct and complete.
Taring distri
ci
a sh
P(719f!bj(,3-7 -0c)
T7��
party in question
I e::�Q -9 • d X Real property
R:
If any pSitim of the residential structure or the land not exceeding one (1) acre that immediately surrounds that structure
is used to produ& income, describe the use and portion
of the property utilized to produce income.
'°PFZOPERTY OWNED BY CLAIMANT IN OTHEWCOUNTIES
County
Township
County
Township
I hereby certify the above statements are true, correct and complete.
SignatVre I claimant
Wss (number and Vroel,
VALUE' j-
1 17 /
USE ONLY��_-��,.
�TRUET AX*
ASSESSEDVALUE
HOMESTEAD'--.
'-NON-RESIDENTIAL
vASSESSOR
VALUES
E�.
AT,1 00 OF TTV
%
VALUE' j-
Land not exceeding 1 (one) acre immediately
surrounding residential improvements-
Other land
(2)
Total land (fine I plus line 2)
(3)
Dwelling
(4)
Residential improvements
Garage
(5)
_it Wks iF
Other improvements
(6)
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(8)
I hereby certify the above is true, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
r, -7-'STANDARD.DEDUCTION ALLOWANCE'-,,
20 _ Pay 20
Lesser of 1/2 Homestead S
VaIrtion or 6,000
Signature of dito I
10 -3 (-c