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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION -
Siate Fortn 5473 (R2 / S92)
INSTRUCTIONS: See reverse side /or liling instructions.
FORM YEAR
HC10
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CERTIFICATION STATEMENT /1
I(We) -` i t day/pf� arch, 19_
I(We) occupied as our principal place esidenc t follovrin d scribe eal property for which a Ho stead P pe Tax.Ci it i4 reby c me �
❑ I(We) owned ❑ Are buying under contract �� �:� ;;;N �) ;1• ;; �,�T��
❑ Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns ihe property or is buying under a coniract.
CONTFACTRECORDED -
If buying on contract, Fee Simple owners name
Recortler s office where convact is recorded Record number Page
PROPERTY DESCRIPTION
Counry Township Tadng disirict (ciry, rown, township)
P I number Legal de5cription
s-o�a� - t � -a-i � � �.
If any portion of the residen6al sirucNre or the lantl not ezceeding one (1) acre ihat immediatety sunountls Ihai sWCture is used to protl ce income, describe the use and ponion of
ihe properry utilized to produce inwme.
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PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Township Counry Township
Signature of daimant
.ereby certify the above statements are true, correct and complete.
Address (number an0 street, ciry, state, ZIP code)
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
� VALUE VALUE VALUE VALUE
Land not exceeding t(one) acre immediatety (�)
sunounding residential improvements.
Otherland (2)
Total land (line 7 plus line 2J (3)
� Dwelling (4)
Residential improvements
Garage (5)
Other improvements (6)
Total improvemenis (line 4 Ihrough line 6) (7)
Total value (line 3 plus line 7) (8)
1 hereby certity the above is irue, correct, and Si9nature of Pssesor Date signed
complete.
Verifying action - SignaWre of Auditor Date signed
STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _
Lesser of 7/2 Homestead $
� Valuation or 52,000
Sgnature of Auditor � Date sign —