Homestead_Johnson (7)�:r,.E �
i �
�o
tfi
CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Fortn 5473 (R2 / S92)
INSTRUCTIONS: See reverse side /or liling inshuctions.
FORM
HC10
YEAR
CERTI CATION STATEMENT �� : _',� p�� ; � ,j--�
��` �} 5 '-l�� � ,�'
I(VJe) certify that on the 1st day ofMarch, 19"
I(VJ/e)9ecopi d as our pri i al place of residence following scnbed real property for which a Homestead Property Tax Credit is hereby;d8imed:
�I (We) owned Are buying under contr � W I l� ; � LuUU
❑ Have a beneficial interest in ihe entity thai is liable for the property ta�ces on the pmperty and that owns the propeny`or is buying under� a contrac /!
�
��l �I
?� i.r . Al- �/:.> )'i�l
- CONTRACTRECORDED / ^ ' " �' ��� -�'��%� �
If Duying on contrac[, Fee Simple owners name
Recordefs office where contract is recortletl . Record number Page
PROPERTY DESCRIPTION
Counry Township Taxing tli5�ric1 (ti to Ship)
�parEel nwaber ��' Legal descnption
U� �
�_
I( any portion o( the residential structure or the land noi exceetling one (1) acre that immeAiatey surtountls that struciure is used to protluce income, Oescribe Ne use antl portion of
the property utilaed ro produce income.
. ��_/�-o��_ax. a�� ���
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry , Township � Caunry Township
Signa re f Uai n
�ereby certify the above statements are true, correct and complete. i0 —�
!/L�.�
Adtlress ( ber and stree uty, stafe, ZIP codeJ � '
�� � �S �; � �F Zit/ - �%� � S
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land not exceeding 7(one) acre immediately (��
surrounding residential improvements.
Otherland (2)
Total land (line 7 plus line 2) (3)
Dwelling (4)
Residential improvements
Garage (5)
Oiher improvements (6)
Totai improvements (line 4 through line 6J (7)
Total value (line 3 plus line 7J (8)
I hereby certify ihe above is true, correct, and Signamre of hssewr Date signed
complete.
Verifying action - Sig�ature of Audiror Date signcd
� STANDARD DEDUCTION ALLOWANCE
19 Pay 19 _
Lesser of 1 2 Homestead c�
Valua' n or 52.000
Sigrawre of AW iror Date si . o�
/ �