Homestead_FordFOPM HC t0 t9i9 . ta Be FileG in Duplicate
P�esc�ibee By Stare Boa�O of iae Commissfoners .
CLAIM FOR HOMESTEAD PROPERTY TAX CREDIT-FOR-YE7tR
SEE BACK FOR FILING INSTRUCTIONS _�[��(oO�
n, aW
�(We) �-�-� �-+" / �� certify that on the 1st day of
.iarch, 19 I, (We) occupied s our principal place of residence the following described real property for
which a Homestead Property Tax Credit is hereby being claimed:
I, (We) ❑ owned G�1�—��i-r�aS- QO-G�GI �o0/—D�i
� are buying under contract
❑ have a beneficial inter� in the taxpayer
Property Description in�(L` County Township
Taxin� District (City, Town, Townshi'): � �y� — — 3
' a3.a�.s
Parcel Number or legal description shown on tax statement:
If buying on contract Owners name ��� simple owneq
Contract recorded in Recorders Offic`� - Record No.� ge�
Ii 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 oi the property utilized to produce income
Any other counties in which individual owns or is buying real property:
�hereby certify the above statement is true, correct and complete
n .,
naaress
County
Township
�y����
ciry. Scaie ana Zip Guoe
' 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 exceedir�t (Q e) a� ir�di�
surrounding residential improvements
Other Land ,,,, r;v ? �; ''� l �
Total Land
Residential Improv�ts
i
Other Improvements
Tn} � Improvements - Li
i�by certify the abo
App
� '
� � •-
Dwelling
Garage
Tolal
plus (7) equals (8)
true. correct. and complete.
True Cash
Value
(t ) .�oo
�2� 3a �o
(3) 3 7 9'�
�q� 2�.2a
(5) —
�g� .Z S�o
c�) 9sO
(g) �770
- ACTION BY AUDITOR -
Assessed
Valuation
.
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i :
S-i-1-79
Date
Homesiead
Valuation
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Date: � ��— / �