Homestead_TeelFOflM HC 10 7979
PrescriGeE By State BwrO ol Tae Commiuioners
To & FiIM in Duplicate
CLAIM FOA HOMESTEAD PAOPEATY TAX CREDIT FOR YEAR 19 79
SEE BACK FOR FILING INSTRUCTIONS QOS+ OI U9 ,,
�'�(We) � ���/ � '� ��J certify that on the 1st day of
arch, 19�9 I, (We) pied as our principal place of residence the following described real property for
which a Homestead Property Tax Credit is hereby being claimed:
I, (We) L�7 owned �� ��-��%v?!lD �xY• %T7- Qot�
❑ are buying under contract ,
O have a beneficial �in�tJgrest in the taxpayer -
Property Description in��„/� � �Co—unty Township
Taxing District (.CiLy.-�nwa; Township): �'�� ��1�-<-i
Parcel Number
If buying on contract: Owners name ��� �""o�e owner�
or legal description shown on tax statement:
.S� ���y �%�- J� �9 � f�
Contract recorded in Recorders Office - Record
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: County Township
hereby certify the above statement is true, correct and complete.
�� ` �� � �
�'SiynaNre . Street ACE�l55 �� Gry. State E ZiD �e
/ y - -� y���s--
' 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 the taxpayer.
- FOR ASSESSOR'S USE ONLY -
Land not exceeding 1 r�j �rE�'fmntsd_�t�
surrounding residential�li pro e��i,s�+
Other Land
Total Land .��N 7 i979
Residential Improvem�t� Dwelling
Ci('
� A�� Gara9E'�'
Total
Other Improvements
Improvements - Line (6) plus (7) equals (8)
py certity the above _is true. correct. and complete.
o� Asussar
True Cash
Value
( � ) .7 B—o
(2) � 7 � O
c3� 9 a � o
(4> /.S 'S�lo 0
(s)
(s� /SJy6o
(�) — °
�s� /S"�� a
- ACTION BY AUDITOR -
Assessed Homestead
Valuation Valuation
/7 v /70
I � Y
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Date: �L/ / � ��
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