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a� t CLAIM FOR HOMESTEAD PROPERTY TAX
� CREDIT/STANDARD DEDUCTION
� : > Sute Fwm 5473 (RS / 10-01)
Prescnbed by the Department of Local Govemment Finance
INSTRUCTIONS: See reverse side !or �ling instructions.
—1
FORM � A -;
HC10 �
�..�
I(VJe) l.Y � certify lhat�p�th9lhst��March, 20_
I(We) occupied as our principa� piace residence the foliowing described real property for which a Homestead Proper�y T�lc Er i ereby Gaimed:
❑ I(We) owned ❑ Ne buying under coMract /n/
�-lave a benefidal interest in lhe eniiry ihat is Iiable for the properry taxes on Ihe property and that owq�pr.oper��4G�n9.u�fl-a�ntract.
II buying am m�trad, Fee Simple ownefs name
Recorders office whera contrau is recorded
Tavnship
Record number � Page
Ya� o�`--a �a � y- � � Leg�CTpfiO� W V� � �/ —� I� IVh1 1pi0perly in Quefl�Qn: (`'
I
r C � Real pmOertY ❑ Mobile Homo p.Q 6 f.l-7)
i( any porlion of Ihe resi0ential sWIXure w ihe Wnd mt exceetling one (1) acre ihal imme�iatety surmunds �hat swciure is used lo produce income, desai6e Ne use antl portion
of ihe property utilized ro produce income.
- /%.33 - �`oo-O�'yi"a/�`=0�/
�'y�'��s��°'�7 ��"�` -'r—' � '"'� "� "� TRUE TAX 4 > �ASSESSE� VALUE �HOMESTEAD` h � T NON-RESIDENTIAL�t�� %•
..�p.tr � �ASS� OR�UjS�10NLYtt���j,���� � VALUE�,;^ ..iy _AT.-100%.OF��TTVr. � " � �V/LLUE?'s� �j a_� �Y.� 3VALUEr ?,� ��i,.d3'
x .,+>F� r
Land not exceeding 1(one) acre immediately `-+3 ��1 �'� �u * 4^�z�`�y �
suvounding residenUal improvements. (� � . `` �. �, �,,.5-i„�,� ���;x . �_;:->.�,r;�,,� �:;.
Oiher land � ��` �'' �°�' '
(Z) ,,�'�,.y�.
�.i
Total land (line 1 plus line 2) �3�
.. 4�,,�y ; � z�.�,y �, ;
Dwelling (4) .� � � �tl�f�'s,'r-a� `�",�'S�•��� -";
Residential improvemenLS . ,� �. ,��
r 'f t^ - +-i`�.,-.� f, -�•'3 =.�r
Garage 5 .�'Te� �r 'fi' >>s�L"+i'3'<�r- `;i�''' -:
� � .s�..):a;��kh`'�..�:+i. �t-
Other improvemenis (6) �, r�� x n-�, � �
;�f.;.�
Tdal improvements (line 4 through line 6) (7)
TUai value (line 3 plus line n (g)
I hereby certify the above is We, correct, and Signature ofassessor Date signetl
complele.
Verifying action - SignaWre otlwditor Date signe0
�'-`.--�z''v-s'k�4i.`i'-i �=�z:etc_''_-�'�xi`:.,.:=`s� .9k,'_'-,=.STANDARD.DEDUCTION�ALLOWANCE v�,:;r.u"....i,.r�.�w��= '* ;...t.: r�s.,'.�i,l+==;f,.
20 _ Pay 20 _
Lesserof 1/2 Homestead
Valuation or 56,000 S
Sy aW otlwd' ot D si n
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