Homestead_Lang4�E Si1tF .
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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Fortn 5473 (R2 / S92)
INSTRUCTIONS: See ieverse side lor filing instrucfions.
FORM
HC10
. YEAR
'^ CERTIFICATION STATEMENT
I(VJe) �'
described real o for which a Homestead Property Tax Credit is hereby claimed:
(We) owned ❑ Are buying under contract
❑ Have a beneficial interest in the entiry that is liable for the property taxes on the property and thai owns the property or is buying under a wntract.
CONTRACTRECORDED � �
It buying on conVact. Fee Simple owners name
Recordets oHice where conVad is recortletl � Recortl number Page
. PROPERTY DESCRIPTION
Counry Tovrtvship a�ting disMp (pry, lown, township)
Parcei number L al descri tion ��^(�
— � �� V
If any portion of ihe residential strudure or Ne land [ exceeding one O acre that imme0iatey surtou s that suucture is usetl m protluce income, descnbe ihe use and ponion of
the properry utilizeC to protluce income.
o� - /%D� D- �D/. Do?3-O�/
� PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Tovmship Counry Township
Signature of daimant
��ereby certify the above statements are true, correct and complete.
Address (number and stree(, ary, stafe. ZIP cnde) �
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAI
VALUE VALUE VALUE VALUE
Land not ezceeding 1(one) acre immediarely �� � -
surrounding residential improvemenis.
Otherland (2)
Total land (line 1 plus line 2) (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 the above is irue, wrtect, and . Signature of Assesor oa�e signed
complete.
Verifying action - SignaWre oi Audimr Date signetl
� STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _
Lesser of 7/2 Homestead $
Vatuation or 52,000
-- i� 9�y�� � n Date signed �_I O ��\
� C�C/
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