Homestead_CauthenFORM HC 10 1979 To Be Filed in Duplicate
Prescribed By State Board of Tax Commissioners
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT FOR YEAR 19 $ 3
SEE BACK FOR FILING INSTRUCTIONS 1005 00ASI
iNe) " ✓��. 0-�- 1\ - `L c -r Qcertify that on the 1st day of
March, 19--Z-3— I, (We) occupied as our principal place of residence the following described real property for
which a Homestead Property Tax Credit is hereby being claimed:
I, (We) Er-owned
❑ are buying under contract
❑ have a beneficial interest in the taxpayer l� 1
Property Description in OtJ- c-Pxn+ County l� /,� Township
Taxing District (City, Town, Township):
Parcel Number
If buying on contract: Owners name
or legal description shown on tax `sAatement:
. A)E f 14 N(.>,Jf% 9 -3 -/a
Contract recorded in Recorders Office - Record No. Page
If any portion of the residential structure or the land, s e ing )are that immediately surrounds that
structure is used to produce income, describe the us n operty utilized to produce income
Any other counties in which individual owns or is buy! rV)l "r ty;� County Township
AUDITOR
®hereby certify the above stateme is true, correct and complete.
'Signature Sweet Address City. S:ate and Zip Code
Individual either owns or is buying under a contract that provides he is to pay the property taxes
on the residence, or has a beneficial interest in the taxpayer.
- FOR ASSESSOR'S USE. ONLY -
Land not exceeding 1 (one) acre immediately
surrounding residential improvements
Other Land
Total Land
Residential Improvements Dwelling
Garage
Total
Other Improvements
I1�lImprovements - Line (6) plus (7) equals (8)
by certify the above is true. correct, and complete.
Signature of Assessor
Homestead True Cash Assessed
Value Valuation Valuation
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-. ACTION BY AUDITOR -
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Approved: 7b4o Date: -.- gm -43