Homestead_Buschd • �iCLAIM FOR HOMESTEAD PROPERTY TAX CREDIT /STANDARD DEDUCTION l• State Form 5473 (R21 5-92) INSTRUCTIONS: See reverse side for (ling instructions. FORM YEAR I t'j C10, L* s linnn CE TIFICATION STATEMENT r' y I (We) U, certify that -on the 1st day -of March, 19_ :-w_ .:,.L, -... I (We) occupied as our principal place of residence the following described real property for which a Home etq r _ ", rty -fax CredrtlWWieby claimed: ❑ 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. CONTRACT RECORDED If buying on contract, Fee Simple owners name Recorders office where contract is recorded Record number Page PROPERTY DESCRIPTION un Township Taxing disld t d ow s P I numb 3 \ Legal dew lion - SC _3 a 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. PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES County Township County Township - •lereby certify the above statements are true, correct and complete. Si[02of d -unant / �J Address (number and street. city, state, ZIP code) ( (0 �17E6 s ASSESSOR USE ONLY TRUE TAX VALUE ASSESSED VALUE HOMESTEAD VALUE NON - RESIDENTIAL VALUE Land not exceeding 1 (one) acre immediately surrounding residential improvements. (1) Otherland (2) Total land (line I plus line 2) (3) Residential improvements Dwelling (4) Garage (5) Other improvements (6) Total improvements (line 4 through line 6) (7) Total value (line 3 plus line 7) (8) 1 hereby certify the above is true, correct, and complete. Signature of Assesor Date signed Verifying action - Signature of Auditor Date signed STANDARD DEDUCTION ALLOWANCE 19_ Pay 19 _ Lesser of 1/2 Homestead Valu on or 52,000 - $ f Auditor Date O f-ED O 0-c)