Homestead_Jennings (2)FOflM HC 10 1979
heuriCeE By State BoarG ot Taa Commissianers
To & Filed in DuDlkate
CLAIM FOR HOMESTEAD PflOPERTY TAX CREDIT FOR YEAH 19 � 3 Q
SEE BACK FOR FILING INSTRUCTIONS ����a b
��(We) �`"""`'�`"�"J� `y�e- °�• ��"'-`-�-- certify that on.the 1st day of
"�vlarch, 19�, I, (We) oc�cupied as our principal place of residence the following described real property for
which a Homestead Property Tax Credit is hereby being claimed: J
I, (We) L�Yowned �� �7��-0��0-1��• O�G� ��
❑ are buying under contract
❑ have a beneficial intere�s/t� in� t�he� �ta'xpayer
Property Description in ��"'--" ' County
Taxing District (City, Town, Township):
v /
Parcel Number or legal description shown on t statement:
� i3/f /3� ��.
If buying on contract: Owners name �'� °�mv'e owner) �� N c'/� NE i.� ,- 3- i2 • � � 3 y a`'
Contract recorded in Recorders Office - Record No. Paqe
Township
If 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 of 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.
�./��� UciT.t� � an �� � /�L.�chJi
'SipnaWre SVret Aoaress �
County Township
Ciry. State ana Zip CoGe
' 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
� 7otal
Other Improvements
�
•7 'Improvemenis - Line (6) plus (7) equals (8)
I I'�by certify the �pove is true.^correct�nd complete.
//. . n _ �,
Sigwmre oi Assessor
True Cash
Value
(1) d`- O o
(Z)
�gj �o- 0
�a> 37�ao
(5) —
�s� 3�c�io
(�) —
Assessed
Valuation
7
/ �O
/aSs<o
�g� 37�zo /a-S�fo.
- ACTION BY AUDITOR -
Da:e
Homestead
Valuation
�70
i�s �a
�� i 9 i9��
Date: �
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