Homestead_KochFOflM HC 10 1979
Reuri0e0 9y State Boam ol ia. Cammissioners
CLAIM FOR HOMESTEAD PROPERTY TAX CREUIT FOR YEAR 19 7%
io Be Fled in Wpliw�e
SE@ @ACK �li �IL�NC INSTP�U�TI�N� goS•boq93
�(We) �� 6"��j ��-�-�-+� �� !u�=� =J certify that on the 1st day of
arch, 19�-9, I, (We) occupie as our principal place of residence the following described real property for
which a Homestead Property Tax Credit is hereby being claimed:.
I, (We) C9�owned a!� / ! _�oZ-.1�O-GD�' �7.� -�o��
❑ are buying under contract
❑ have a beneficial ii�t rest in the taxpayer
Property Description in County � Township
Taxing District ( ' , , hip):
Parcel Number or egal description shown on tax statement:
�r, N£ y S4,'y 3d-3-i�, 18�,Y.3eQ,
If buying on contract Owners name ��ee s,mo�e ow�e�i
Contract recorded in Recorders Office - Record No. Page
� 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:
certify the above statement is true, correct and complete.
� �� ��'������
�.. , e��.,«
County Township
-r�7633
Clry. State and 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 ihe taxpayer.
- FOR ASSESSOR'S USE ONLY -
Land not exceeding 1(one) acre immediately
surrounding residential improvements
Other Land
Total Land � � � � �
Residential Improvem s Dwelling
��L � a �� Garage
Total
Other Improvements �
T �mprovements ne
i�oy certify ihe abov�
ot Assessor
o�r61�ry��e�f�-�f
�
true. cor�AAfi$� complete.
True Cash
Value
( � ) .� �o
(2) � ��� n
�3> ya � �
(4) ��c70
(5) � 7 c�
�6� �'a x o
c�> 1`fS�o
(g) -1 !�Q
�T�,����`���������
Assessed Homestead
Valuation Valuation
��-79
oa,�
Approved: � G�G(� ��L�� ` Date: _�J� - 7 �