HomeMy WebLinkAboutHomestead_Brock0 jCLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR
} CREDIT /STANDARD DEDUCTION HC10
State Form 5473 (R614-03)
Prescribed by the Department of Local Government Finance
INSTRUCTIONS: See reverse side for filing instructions.
%?6� �aCERTIFICATION STATEMENTrz i ; �^ ,�
I (We) certify that on the 1 st day of March, 20_
I (We) occupied as our principal place of residence the following described real property for which a Homestead Property Tac Credit is hereby daimed:
I Have owned ❑ Are buying under contract g A
Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns t ;Po pN dj�jF IsJbu g r a nuad.
y
' r,'•' �s- sb-. fi_ c' s' �} �. �„ �," ai�E', ta�zg�j°, r�S�: iCONTRACP .RECORDEDs"�'`'�>+�i::3�'
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If buying on contract, Fee Simple owners name
Recorders office where contract is recorded I /L� wfl Page GI Ft d ul!b AUDI O
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- A�SSESSORLSE ONLY- -•
P,ERT,Y,' DESCRIPTION
County
Tavnship
Taxing district (city, town, township)
mi mher
is'DD
des ri do Is the property in question:
q— O zo ❑ Real property ❑ Mobile Home(I.C. 61.1 -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 utilized to produce income.
OHO.
N VALUEr
`'�*PROP.ERTY:OWNEDIBY.CIAIMA W NOTHER 'COUNTIESy.�"'`.�,�Tp!�5�}s3rn.
County Township
Cou Township
I hereby certify the above statements are true, correct and complete.
Si ature claim nt .
6 ddre z beryrq street, city, state, ZIP code)
surrounding residential Improvements.
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- A�SSESSORLSE ONLY- -•
TRUETAEND -ty..
s��
ASSESSEDVALUE
"'ATE700
4 --�-�- --,.�
HOMESTEADSe
-x
` NON - RESIDENTIAL'
u �:
- YALUEv
$t.- .__.,..a. k;ge
!c.,.>.... %OF,
N VALUEr
s-.: VALUE.a`ki'isy .
Land not exceeding 1 (one) acre immediately
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surrounding residential Improvements.
Other land
(2)
f �7''i
c SI R
�'.Y",
Total land (line 1 plus line 2)
(3)
Dwelling
(4)�f
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r .�
id r�i3
r`r
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Residentiallmprovements or Annually
Assessed Mobile I Mararfac9lred Homa
Garage
(5)
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f�-Mi = y '; v »ij ;
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Other improvements
(6):^x3'
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Total improvements (line 4 through line 6)
(7)
Ral value (line 3 plus line 7)
(6)
1 hereby certify the above Is We, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
20_Pay 20_
Lesser of 12 Homestead
Valuation or 535.000
Signature of Auditor