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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Form 5473 (R2 / S92)
INSTRUCTIONS: See reverse side for (ling inshuctions.
FORM
HC10
YEAR
� CERTIFIC N STA ENT
%
I(We) certify that on Nnen '1 st day of March, 19_
I(We) occupied as our principal place residence the following d � ed real property t hich a Homes�r� �yWredit is hereby claimed:
❑ I(We) owned ❑ Are buying under contract ' • /-
❑ Have a beneficial interest in the entiry that is liable for the property taxes on the property and that wns thepm �rty o b' n r a coniract.
r nN7Y AUDITOR
CONTRACTRECORDED � ' " `
If Duying on contract, Fee Simple owners name
Hecortlers office where conVact is recortletl Record number Page
PROPERTY DESCRIPTION
Cou Township ' Tadng d�strict (ci , , t wnshi )
rce number � Legal description
OS-D/93S-�D � �/'-3 /� /�C,
If any ponion of the resitlentlal struciure or the IaM noi exceeding one (i) acre ihat immetliatety surrountls ihat swcture is used ro produce i`urome, describe Ne use antl ponion ot
the property Wlized to produce incrome.
�'G -�7 0 9- 0300 - a�/. 9.3.� =6�/
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Township Counry Township
Sigqature ot claimant
areby certify the above statements are true, correct and comptete. �
Atltlress (number antl slreet, dry, sfate, ZIP codeJ
�
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land not exceeding 7(one) acreimmediately ��)
surtounding residential improvemenis.
Oiherland (2)
ToWI land (line 1 plus line 2) (3)
Dwelling (4)
Residential improvements
Garage (5)
Oiher improvements (6)
Total improvemenis (line 4 through line 6J (7)
Total value (line 3 plus line 7J (8)
I hereby certify ihe above is Irue, cortect, and Signawre of Assesor Date signed
complete.
Veritying action - Sgnature of AuAitor Date signed
STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _ .
_ Lesser of 1/2 Homestead S
Valuation or 52,000
5� ure ot Au itor Date sign� _—O� Q/
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