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CLAIM FOR HOMESTEAD PROPERTY TAX FORM F—YEAR
CREDIT/STANDARD DEDUCTION
State Form 5473 (R5110 -01)
Prescribed by the Department of Local Government Finance
I (we) (7$-MAA-A Cjj- I Y certify that on A ofANh, 20
1 Pt6"i
I (We) occupied as our prin (r-I place of residence the following described real property for ,Akclhi a Homestead Property Tax Credit is hereby claimed:
❑ I (We) owned ❑ Are buying under contract
lave a beneficial interest in the entity that is liable for the property taxes on the property and that owns the pJ� s 4W, 'rt under "o�tract.
CT So, -1 c - on - t!ac -
-coKTRACT.RECORDED.-;'Q�',,7
If buying on contract, Fee Simple owners name
Recorders office where contract is recorded Record number Page
?.V-Uk�7; L'4�Zv-i W;,ffr R� PROPERT, Y.-DIESCREPTION; i i � 1 � -` �, r-�
County
Township
Taxing district (city, town, township)
jTj n ber
_00
Legal de
&��
Is the property in S�Wion:
ro&Keat property ❑ Mobil. Homo (/.C. 61.1-7)
If any portion of the residential structure or the Land not exceeding one (1) acre thatimmediately surrounds that structure is used to produce income. describe the use and portion
of the property utilized to produce income.
PFfOP.EAT;Y�bWISIECFBY CLAIRA-14TWOTHER-iCOLHATIES,
1
k�SE§SiD ��COE
County Township
County
- -
Township
I hereby certify the above statements are true, correct and complete. N
Si at of claimant
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Signature of Auditor
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SSIESSOR"USECINLYM -
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k�SE§SiD ��COE
;"�H0ME'S"TEAD*
4NON�RESIDENTIAlf.%z'1:1% �fi
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Signature of Auditor
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Land not exceeding 1 (one) acre immediately
Date signed3
surrounding residential improvements.
Other land
(2)
Total land (line I plus fine 2)
(3)
Dwelling
(4)
Residential improvements
Garage
(5)
11 Q X'ns.'
Other improvements
(6)
4-4Tk
Total improvements (fine 4 through line 6)
(7)
Total value (line 3 phis 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
XpT'*t'!-WNA;- DARI),DEDUCTION�ALLOWANCE�§�,;4,',-I
20 Pay 20
Lesser of 1f2 Homestead
Valuation or $6,000
Signature of Auditor
j
Date signed3