Homestead_MerchantSi�I(
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CIAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
Siate Fortn 5473 (R2 / 5-92)
INSTRUCTIONS: See reverse side lor filing instrucfions.
FORM
HC10
YEAR
CERTIFICATION STATEMENT
1(We) Ns%ti ti T N� �( Vl/� � , ity at on st y arch, 19_
I(VJe) occupied as our principal piace f residence the tollovring scribed real property for which a Ho �r erty T ereby claimed:
❑ I(VJe) owned ❑ Are buying under contract G
❑ Have a beneficial interest in the entiry ihat is Iiable for the property taxes on the property and that owns the p��rVE ��in�g under a ntract.
U �-
CONTRACTRECOHDED� '
If buying on contract, Fee Simple ownefs name �(�
1esoN couN�
Recorder's office where contraci is recortled , Recortl number Page
� PROPERTY DESCRIP ON
Counry i ip iaxing � t� t(dry, t , township) �
/ %�j � o�✓ �
Parcel number Legal descrip
00�- p�/ �iZ-p
tl any portion of Ne residenGal strucWre or the lantl not exceeding one (1) acre that immediatety sunounds that sWCture is usetl m produce income, describe ihe use and ponion of
the property uulized to produce income.
o��o -�O o3l0 - -L�''S"/o?- Do�
� PROPERT.Y OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Township Counry TovmShip I
Signa of tlaimant �
ereby certify the above statements are true, correct and complete. �
Atltlress (numbe! and shee�f, ^/Gry�, stafe, ZIP Code) U I
R�� D 7J'B OWfHJUr�IL��%�% /7�/��
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land not ezceeding t(one) acre immediately (� �
surrounding residential improvemenis.
Other land (2)
Total land (line 7 plus line 2) (3)
Dwelling (4)
Residential improvements
Garage (5)
Other improvemenis (6)
Total improvements (line 4 through line 6) (7)
Total value (line 3 plus line 7) (8)
I hereby certify the above is We, wrrect, and _ Signature of Assesor Da�e signed
compiete.
Verifying action - SignaWre of Audiror . Date signetl
� STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _
ser of 7/2 Homestead �
alu io or 52,000
SignaWre oi Audiror Date signetl
, � }-6.-od