Homestead_TichenorC�,SCCIC�G.i^. il}� St3t2 YL13LC1 OT '1'dX I;CIlT[Tt3.SS1uRPS5
CIAI�� FOR Hq4ESTEAD PROPERTY TAX CRQ)IT FOR 1'F�1R ]9�S
. SEE BACK FOR FILING INS1RlIC'fIONS Q05 ������ •
I, `,r�e) 'T �( r�J,ID� _01 [`� lt.Q1n mctl , certifS' that on the�2st� day of
�: 19 , I, occ�ied as our princioal olace of residence the folla,ring described real
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f���,s•_1ty OT c.t', a t�t�ad ?LVpeLty T3X �edit is heseby bPin9 nl?imYi;'
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` z, cwe� t�d"� . �� /7-/0?- �a-�/, %9� ��!
o � �� �� �tr� _
� have a be�eficial interest in the taxnayer
Pronerty Description. in s� � T� `�h� �O�t}' � �uP
Taring District (City, Toum, �) � P���y ( a- 3� �.�t y—�}C. ��+!" _ �nn.
Parcel ihnnber or legal description shvan on ta�2' staterent:
If buyina'on oontract: Owners i�[�e (fee si�le cNmes) -- -
Nntract reooaied in Remrder's Office - Reoo�d bb. Page
Zf any portio¢� of the residential structure or the land, not �eerling one (1) acre that
inmediately surro�3s that stru�tiae is used to pxociuce �^n*+�, desct'ibe tiie � use and Pnrti.on of
the property utilized to px+oduoe imo�re •
Any other �unties in which individual owns ar is buying real pmperty: � � ' 4bwnstuP
T hezehy c the above statenent is true, aorrect ani o�plete.
� `�' �° �� i�" •�.�.street Address c�ty, state ana z�p a
Si ture
*Indivirlual either owns or is buying �er a cvntraet that provicles .he is to pay the
property. t�aes on the residence, or has a beneficial interest in the taxFiayer. .
. - FOR ASSESSOR�S U5E ONLY -
Ttve Cash
Value
Land not e�weeding 1(one) acre inanediately . �O O
sisroiu�ding x�sidential iicguovarents (1)
Qther Iarx3 (2) .� O
Toral t,ana cs) / `% 3 °
PPSidential I�mvares�ts �� �q�
Garage
Zbtal
Other I�rovsnents
(5)
(6) 2Sq °
(7)
� ' irtg�xw�e�ts - Line (6) Plus (7) equals (8) (8)
I hesebY �ertifY the above is trve, correct, ard mrg�letP.
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- ACTION BY AUDIT�R _ ry
Date: �` / �`U`�
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