Homestead_Clark (5)CLAIM FOR HOMESTEAD PROPERTY TAX FORM YEAR
CREDITISTANDARD DEDUCTION HC10
State Form 5473 IRS 14-03)
Prescribed by the Department of Local Govemment Finance
INSTRUCTIONS: See reverse side for riling instrmtions.
3Z, tCERTIFICATION STATENIENT>. -%v.-. -!f
I (We) V k [Q— X) �- - certify that on the 1st day of March, 20_
I (We) occupied as our principal place of*d2c:t Following described real property for which a Homestead Property Tax Credit is hereby claimed:
1;bI (We) owned ❑ Are buying under contract
lave 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.
�a� -�,�z�i�ZCONTRACT�RECORDEDi, I j
If buying on contract, I" Simple owner's name,
Recorder's office where contract Is recorded Record number Page
1
'3-1 41W PkOPERT'�Y-DESCRIP.TION*,v•
County
Township
Taxing district (coy, town, hip)
I M Z�E
Parcel number
Legal description
Is the property In question:
Wb - 0 1 H LA L- W O
Z)6 - I- I a 11- 6
1 ❑ Real property ❑ Mobile Home (W. 51.1-7)
If any portion of the residential structure or the land not exceeding we (1) am that immediately surrounds that structure is used to produce income, describe the use and portion
of the property utilized to produce income.
-M—;�0-i.;g.�--.�-74P.R(jP-ERT-,Y.-dWNED; (BY.CLAIM4NT; IN'OTHER!-COUNTIESro;:'5�r�r-`-�c.?F:nz 4,0 �XM�„2
County Township
[7-
County Township
I hereby certify the above statements are true, correct and complete.
Signature of rJalmant
W(number and street, city, state, ZIP code)
�STAN6ARD DEDUCTION'ALLOWANCE•,
20 _ Pay 20
Lesser of 112 Homestead
HOMESTEADS�
-NON-RESIDENTIAL�,
'
Signature of Auditor
Data �,gned_,
Land not exceeding 1 (one) acre lmmediatety
surrounding residential Improvements.
Other land
(2)
Total land (fine I plus line 2)
(3)
Dwelling
(4)
7-4,
Residential improvements or Annually
Assessed Mobile I Manufactured Home
Garage
,fitter' improvements
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(8)
I hereby certify the above is true, correct, and
Signature of Assessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
�STAN6ARD DEDUCTION'ALLOWANCE•,
20 _ Pay 20
Lesser of 112 Homestead
Valuation or 535,000
Signature of Auditor
Data �,gned_,