Mobile Home_McCoy C HOMESTEAD U PROPERTY TAX
Y
CREDIT/STANDARD LAIM FOR DEDUCTION F 1 I Eo 2., 1 YEAR
SrZe State Form 5473(R6 I4-03) I
Prescribed by the Department of Local Government Finance r1 8- INSTRUCTIONS:See reverse side for tiling instructions. APR 1 S 2005
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0.;}f !,-- .- I � •: - "�` '�:'-" -- • � CERTIFICATION STATEMENT • _-. . -
e L 4
I(We) Gjas t ' jj tl of March,20_ - -I(We)occupied as our principal pla of residence the following cribed real property for which a Homestead Property Tax Credit is hereby claimed:
❑ I(We)owned ❑ Are buying under contract
• Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns the property or is buying under a contrr t.
.-,:u,>:"ti.- x.4.4:'-t. r :12:14; ?.,-:--,r ,r z '.. "t CONTRACT:RECORDED•:. . _..-. ._- v -
It buying on contract.Fee Simple owner's name
Recorder's office where contract is recorded Record number Page
Wa .r.€ . =:.,- ,. - . !'oa_. PROPERTY DESCRIPTION°%- :,'.. `• - - -cr t a.. : .: ,.
County Township Taxing discj(city,town, township)
Pare.- ' • bar Le 91al essccririptio�Gl Is the property in question:
I arst_ 33 - a f I f) �1 Ij �.s ❑ Real property tobile Homo(LC.6-7.1-7)
any portion of the resident. - ct a or the land not exceeding one(1)acre that imme•lately surrounds that structure i used to produce income.describe the use and portion
of the property utilized ttoproduce Income. al I t'w'
1
N ateI
k1?.f§4 at,.c4i .4-,,�T" y.:: +PROPERTY OWNED BY CLAIMANT IN OTHER`COI :--_ES' - t, I ^? ._:- -'•i.,"
County Township County Township i
I hereby certify the above statements are true,correct and complete. Signature//o�f 0—of—claimant /1 M
La'1_O A.aiL Y ' e eA L.,
Address(number and street,city,state,ZIP code) U
OR. R• li i3oX a 3 q Pr, nc —k-on t -�h) 424n? 0
Atnr ' ASSESSOR USE.ON Y . _ : TRUE TAX ASSESSED VALUE HOMESTEAD' NON-RESIDENTIAL,.
ic21 rig. _..£ amp. rz. . ." . VALUE • AT 100/dOFTTV —S °VALUE'''--? • }. _VALUE .:
Land not exceeding 1 (one)acre immediately
surrounding residential improvements. (1) _
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Other land (2) -
Total land(line I plus line 2) (3)
Dwelling (4)
Residential improvements or Annually '-
Assessed Mobile I Manufactured Home Garage (5)
Other improvements (6) I
Total improvements(line 4 through line 6) (7)
I
Total value (line 3 pits line 7) (S) I
I hereby certify the above is true,correct,and Signature of Assessor Date signed
complete. 1 n
Verifying action-Signature of Auditor \I� tL \1 ,�/\\� I. II L Date signed
— _ t� •-- ,�<- .__ •_' "- -STANDARD.DE000TION ALLOWANCE'.` :- ': "- "
<_..r,, 20 Pay 20
O\\ Lesser of 112 Homestead $
O\\, , valuation or S35.000
Signature of Auditor - I Date signed
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