Homestead_SimmonsaE �"R°, CLAIM FOR HOMESTEAD PROPERTY TAX
; �':� CREDIT/STANDARD DEDUCTION
�;��� Sta;e Form 5473 �R2 / SA2)
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INSTRUCTIONS: See reverse sid�r7iling
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FORM
HC10
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YEAR
.e) _ � certify t on ihe 1 st day of March, 79_
a) oc pied as our pr cipal place ot residen th follow scribed real property br which a Homesiea . a T z�rediF�s hereby claimed:
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❑ I(We) owned ❑ Are buying under coniract � AUDITOR "'
❑ Have a beneficial interest in the entiry that is liable for the pmperty taxes on the property and ihat owns the property or is buying under a wntract.
' - CONTRACT RECORDED - � - .
It buying on contract, Fee Simple owner's name � � . , �
Recortler's oHice where contract is recorded Recortl number Paqe
County
It any ponion of the resid
ot the properry utilized ro
- PROPERTY DESCRIPTION
� ' Township � . Taxing district (ciry, fown. township) ' _
legal description
- � ��",3-� o� � S L
strucmre or the land not exceeding one (7 � acre Nat immediatety surmuntls that structure is used m produce income, descnbe the use and portion
ice income. �
- -� - a�i �as`o�/
PROPERTY OWNED BY CLAIMANT IN OTHEfi COUNTIES
Coun�y Township County Township
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��eby certify ihe above statements are irue, correct and complete. �9 •�re _ � ciaimant '
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Addreu (number and sbeet. aty, s(ate. ZIP wde) , � r`
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE •
Land not exceeding 1(one) acre immediately
surmunding resideniial improvemenis. ��) �
Otherland (p)
7otal land (line 7 plus line 2� (3)
Dwelling (4) - � �
Residential improvemenis
Garage (5) . �
Other improvements (6)
Total improvemenis (line 4 through lina � (7)
Total value (line 3 p�s line � (g) '
1 hereby Certify ihe above is true. CorreCt, and Signature of Assessor Date signed
complete.
'ying action - Sgnature of Audimr Date signetl
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19_Pay79_
Lesser of 7/2 Homestead
Valuation or 52,000
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SgndNre ot Autlitor vaie s m
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