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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Form 5473 (R215 -92)
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INSTRUCTIONS: See reverse side for filing instructions.
FORM - ---1
YEAR
HC10 - v/
I (We) _ certify that on the Isbday,o( MII SFh. 19
I yyM /1+Ji J N d
®) occupied as our principal place esidence the following described real property for which a Homestead Propedydax tl()shereby claimed:
LI I (We) owned ❑ Are buying under contract HH
❑ 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.
CONTRACT RECORDED
It buying on contract. Fee Simple owner's name
Recorder's office where contract is recorded Record number Page
PROPERTY DESCRIPTION
County
Township
Taxing dismct (city. town. township)
Parcel number legal tlescription
nn�z- i 3 -0.0 P-,L, E n�s) 9 --a�:l_1 g H(
h 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.
�{
I PROPERTY OWNED BY CLAIMANT IN OTHER COUNTIES
County I Township I County ITownship
certify the above statements are true. Correct and complete.
Address (number and street. City. state. ZIP code)
of claimant
.Q3 16 0X30
ASSESSOR USE ONLY
TRUE TAX
I ASSESSED
HOMESTEAD
NON - RESIDENTIAL
VALUE
VALUE
VALUE
VALUE
Land not exceeding 1 (one) acre immediately
surrounding residential improvements. 1
(1)
Other land
(2)
Total land (line I plus line Z)
(3)
Dwelling
(4)
Residential improvements
Garage
(5)
Other improvements
(6)
Total improvements (line a through line 6)
(7)
Total value (line 3 plus line 7)
I (g)
I hereby certify the above is true. correct. and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
I
19 _ Pay 19
Lesser of 112 Homestead
Valuation or 52.000
S
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