Homestead_CoxCLAIM FOR HOMESTEAD PROPERTY TAX
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CREDIT /STANDARD DEDUCTION
State Form 5473 (8215 -92)
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INSTRUCTIONS: See reverse side for filing instructions.
FORM
HC10
_ .rTr-
YEAR
_ CERTIFICATION STATEMENT
(�-•'7I.1I�-
I (We) if lfibt on tfi "e lrscday of March, 19_
71(W ) occupied as our principal place of a idence the followi described re roperty for which a Homestead Property Tax A,dit is h by aimed:
(We) owned ❑ Are buying under contract L" .r- ✓,.
❑ Have a beneficial interest in the entity that is liable for the property taxes on the property and that ownsC propeny_or,Is buying.lf[idei a contract.
CONTRACT RECORDED
If buying on contract, Fee Simple owners name
Recorders office where contract is recorded
Record number
Page
PROPERTY DESCRIPTION
Coun
Township
Taxing district (dry, town, township)
Parcel number
00-00 -oo
Legal description
3- 3 -i a 75
If any portion of the residential structure or the WM 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
hreby certify the above statements are true, correct and complete.
County Township
Signature of daimant
a nx
Address (number and street, city, state, ZIP code)
ASSESSOR USE ONLY
TRUE TAX
VALUE
ASSESSED
VALUE
HOMESTEAD
VALUE
NON - RESIDENTIAL
VALUE
Land not exceeding 1 (one) acre immediately
surrounding residential improvements.
(1)
Other land
(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)
I 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
Valuation or $2,000
$
ignature of Auditor
22M 0
Date signed