Homestead_Puckett��<
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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Fortn 5473 (R2 / S92)
INSTRUCTIONS: See reverse side lor filina instructions
FORM
HC10
YEAR
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CERTIFICATION STATEMENT �
I (We) � certify thaf��e�sf��0larch, 19_ .
I(We) ied as ou ' c' a
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❑ Have a beneficial interest in the entiry thai is liable for the property taxes on the property and that owns the{�rop�erty a-is ,, 99twrle"4.'."w'°�t.
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CONTRACT RECORDED
It buyirg on contract, Fee Simple ownefs name -
Recordefs oKKe where contraci is recortletl � Record number Page
PROPERTY DESCR TION
Caunry � Township 7" district (dry, rown, to�mship)
Parcel number legal description
- �3-00 -� (.J /U-3-1�. l.00
If any portion of Ihe residential sWdure or the Wntl not exceeding one (1) acre ihai immedia[ey surtounds ihat sVUCture is used to proGuce income, deuribe che use and portion of
ihe praperry utilized to produce income.
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PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Township Counry Township
Signat of Gaimant
ereby certity the above statements are true, correct and complete. '
Atld e' umber st2ef, city. state, ZlP code) - '
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAI
VALUE VALUE VALUE VALUE
Land not exceeding 1(oneJ acre immediately (� �
surrounding residential improvements.
Otherland (2)
Total land (line l plus line 2J (3)
Dwelling (4)
Residential improvements
Garage (5)
Other improvements (6)
Total improvements (line 4 through line 6) (7) .
Total value (line 3 plus line 7) (8)
I hereby certify Ihe above is true, correct, and Signamre of hssewr Date signed
complete.
Verifying action � Signature ot Auditor Dare signed
� STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _
Lesser of 1/2 Homestead �
Valuation or S2,000
Signature of Autlitor Date signed