Homestead_BurkettCLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR
CREDIT /STANDARD DEDUCTION HC10
Slate Form 5473 (R6I4-03)
Prescribed by the Department of Local Government Finance
INSTRUCTIONS: See reverse side for filing instructions.
I (We) I certify that on thfe 1 st day of .4 arch�20
(We) occupied as our principal plat of residence the following described real property for which a Homestead Prfpeny Tax Cred hereby claimed:
❑ I (We) owned ❑ Are buying under contract y i j [ff4
_ n
Have a beneficial interest in the entity that is liable for the property taxes on the property and that
If buying on contract, Fee Simple ownees name
where contract is recorded
Record number I Page
_ —_ . -- -- -" a -'s e�?� :73s47A:i1F9'�']"a s" 30 -
, S PROP,ERT.Y DESCPJP.TidNiv -; 4— ac-s x_r:s..s- x;='a.WnWQ.kr c'
County
Township
Tadng district (city, town, township)
P ce number
3(o y5
Leg 'p'
Is the property in question:
proper❑
(number and street, city, state, ZIP code)
—3
Land not exceeding 1 (one) acre immediately
Real property ❑ Mobile Homo ( /.C. 6-1.1 -7) .
H any portion of the residential structure or the lana 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. � J��) ,10-y"
�✓ v1,,/r
U - 7' -40A/
0. kdikffkt* OWNED`BY,CLAIMANT IN'OTHERCOUNTIES',
County
Township
County Township
I hereby certify the above statements are We, correct and complete.
ignature of clai ant
, Wql) %,OFTTV
ZIA
(number and street, city, state, ZIP code)
Was
/ fi ,
/V
- 'ASSESSOR�USE ONLyt'q
'hRUETAXX��+
ASSESSED VALUE
HOMESTEAD�Ys''
IJO RESIDENTIAL r
'
, Wql) %,OFTTV
ZIA
VALUE
. .kVALUE s6p{ .
Land not exceeding 1 (one) acre immediately
(f)
frz�s rt
surrounding residential improvements.
Other land
(2)``Y
e
- -'
Total land (line 1 plus line 2)
(3)
Dwelling
g
()"`�""_s"�
n,�xr fflgr
g.
Residential improvements or Annually
Assessed Mobile I Manufactured Home
Garage
5
Other improvements
(6)
,*Wr PO-1
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(6)
hereby certify the above is true, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
20_Pay 20_
Lesser of 112 Homestead
vauabon or E35.000
Date signed