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���� CLAIM FOR HOMESTEAD PROPERTY TAX
_� CREDIT/STANDARD DEDUCTION
' State Porm 5473 (R2 / 5-92)
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INSTRUCTIONS: See reverse side lor �ling instructions.
..��, ` . . . . -. _ - . - • •-`:�CERTIFlCATI
FORM YEAR
--T yHC10�' ` � �
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I(we) _�C�� -C!/l+�-G. cert�ry tha✓t o�n,theist_tlay ot�March. 79_
�) occupied as our principal place of residence the following described real property for which a Homeste P operty Tau Credit is�hereby daimed:
tJ I(We) owned ❑ Are buying under contract
❑ Have a beneficial interest in ihe entiry that is liable for the property taxes on the property and thai owns the property or is buying under a contract.
_ �.; '. � .. CONTRACT-RECORDED � ... . . .. .... .. � . .._ � ;., ... . Ci�... �- .:' . ;...1;'-„ �
IIf Duyirg on contraa, Fee Simple owners name
Recortler's oHice where contraa is recortled Record number Pa9e
Coun Township
P�/y) nf mDer %�� Legal des
V(�—O�ll —`'Ll
If any portion of t�e resitlenfial structure or the land not
of Ne property u0lized to produce income.
PROPERTY-0ESCRIPTIO!
Tacing tli5trid
, �e �
� aae [hat immediatey wrrounds that struaure is used to produce income, describe the use antl portion
� PROBERTY OWNED BY CLAIAAANT IN OTMER COUNTIES��
.".ounry Township Counry
��eby certity the above statements are irue, correct and complete. cur� an2
C,
Address (number arnl sbeet. �ry, stafe, Z1P code)
�c ro 2 4'GS � ST��f j 1� FD�P� /'R
Township
� ASSESSOR USE ONLY � . TRUE TAX. ASSESSED HOMESTEAD NON-RESIDENTIAL.
� _ VALUE VALUE VAWE VALUE �
Land not exceeding 1 (one) acre immediately ��. - ,_ �� � �� �
surroundingresidentialimprovemen[s (�) � . `� '
Other land (p) �'�� r
�
Total land (line 1 plus line Z� (3�
Dwelling (4) � - .. �
Residential improvements . ,
Gara9e (5) - � ..
Other improvemems (6) � , �
Total improvements (line 4 through line � (7)
Total value (line 3 p�s line � (g) �
1 hereby cehity Ihe above i5 irue. corrett, and Signature oi Assessor Date signed
complete.
Wifg adion - SgnaNre of Audimr Date synetl
�
79_Pay19_
Lesser of 7/2 Homestead
Valuation or 52,000
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