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)