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CLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR
3 CREDIT /STANDARD DEDUCTION Hc�o
State Form 5473 (R614-03)
Prescribed by the Department of Local Government Finance t�!I
INSTRUCTIONS: See reverse side for filing instructions.
I (We) J (</�Llrx� /! I /� certify thrYon the 1st day, of March, 20�%�
1 (We) occupied as our principal place of residence the following escribed real property for which a Homestead Pr " �� I" I� "'aV,'
9 P P Y �S NC�pVUYbvrHbyDii C' 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 property or is buying under a contract.
�. iCONTRACT.' RECORDED.,:
LT.S.TiJ
If buying on contract, Fee Simple owner's name
Recorders office where contract is recorded Record number Page
P,R.OPERTY.DESCRIP IONf�- ? - -,�,5. +'t':.r. .'i
County
Tavnship
County Tmnship
Taxing trict (city, t wn, township
sdx
Address (number and street, city, state, ZIP code)
Vafuabon or E35.000
P ber
escri i n
/�
Is the ro
p perry in uestio�
(J C/
..+— �d
Real property ❑ Mobile Home (I.C. 6-1.1 -7) .
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 ufilaed to produce income.
> �'�,�>'rs����•"v-�� �` sPROPERTY ;OVYNEU';BYCLAIMA'NT11J : OTHER' COUIJTIESc� ,'��.._�;,�%j�'�,rsg±';�.�'
County
Tmnship
County Tmnship
I hereby certify the above statements are true, correct and complete.
Signature of claimant ��pp
K 7�.�'yc., ♦7K�
Address (number and street, city, state, ZIP code)
Vafuabon or E35.000
ASSESSOR USE ONLY y s3` .'�
5=.'�°'r....2, "y i � -u,
*- +TRUE TAX'-
i 'W.iXALUE 4°F ..
ASSESSED VALUE
AT ;100 A_OFT7V
HOMESTEAD
4;..VALUE �'
NON RESIDENTIAL �'` a
-` o''`VALUE sp a
Land not exceeding 1 (one) acre immediately
S
Vafuabon or E35.000
"`•';s�.c`` E`- `1'H
a
surrounding residential improvements.
(1)
Other land
(2)
Total land (line 1 plus fine 2)
(3)
Dwelling
9
(4
Residential improvements or Annually
,,„
i9a
Assessed Mobile / Manu(acblred Home
Garage
(5)
-"* �
rs' .�?ul MW
Other improvements
(6)i`•Y��
r
Total improvements (line 4 through line 6)
(T)
Total value (line 3 plus line 7)
(3)
I hereby certify the above is true, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
!97- TANDARUMEDUCTION`ALLOWANCE'tl �' ?' "� ""': •. �"'r,1`.' "-�^" "=^
20 _ Pay 20 _
Lesser of 112 Homestead
S
Vafuabon or E35.000
Signature of Auditor
Date signed