HomeMy WebLinkAboutHomestead_EnglehardtCLAIM 4FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
N State Form 5473 (IRS 14-03)
Prescribed by the Department of Local Government Finance
INSTRUCTIONS: See reverse side for riling instructions.
I (We) IL-
I (We) occupiqs our Wpnnapal place of residence the following
I
FORM
HC10
YEAR
W, Sj it (an If%—&- certify that on the 1st day of March, 20_
real property for which a Homestead Property Tax Credit is hereby claimed:
I (We) ownQ ❑ Are buying under contract
Ilave a beneficial interest in the entity that is liable for the property taxes on the property and that owns the property or is buying under a contract.
RECORD EDI'.-
If buying on contract, Fee Simple owners nerna
Recorder's office where contract is recorded Record number Page
PRoPERTYI)ESCRIPTION
County
Township
county nship
T�l
County
T
Tod
d brict o%vri
O"Shlp)
Pagel
Land not exceeding I (one) acre immediately
Leg.[ description
Is the 6kxn
question:
yt_ CCO04 (0_ (2!�
I J,54eal
Property ❑ Mobile Home (W. 6-1.1-7)
It any portion of the residential structure or the land not exceeding we (1) am that immediateN surround, th-t'structure is used to Produce income, describe the use and portion
of the property utilized to produce income.
(2)
-'P4' Wr?
T=ASSESSOR'LIS E W,
I
County
Township
county nship
T�l
I hereby certify the above statements are true, correct and complete.
Signature of claimant
W(number and street, city, state, ZIP code)
-'P4' Wr?
T=ASSESSOR'LIS E W,
I
TRUE
SSESSEDAVAL:UE
;�-AHOMESTEAD4
53 -NOWRESIDENTLAL-'�-,
7 a1NLXX-Q
:T " -
V
I .
VATA00WOFjT V
Dat
1 71 Fr-�M4
Land not exceeding I (one) acre immediately
surrounding residential Improvements.
Other land
(2)
'IRA;
Total land (line I plus line 2)
(3)
Dwelling
Residential improvements or Annually
(4)
Assessed Mobile I Manufactured Home
Garage
(5)
Ober improvements
(6)
. kil
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
ki
20 _ Pay 20
Lesser of 12 Homestead
Valuation or 0 335,000
$
Signature of Auditor
*16'L-1
Dat
1 71 Fr-�M4
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