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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Form 5473 (R2 / S92)
FORM
HC10
YEAR
INSTRUCTIONS: See reverse side foi liling inshuctions. �
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CERTIFICATION STATEMENT �
1(VJe) , c� tlf�t yn ��Q�t day of March. 19_
I(4Ve) occupied as our p cipal place of residence the fo owing described real property for which a Homeste roperty Ta�c Credit is h� by claimed:
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❑ I(We) owned ❑ Are buying under contract ' � -�
❑ Have a beneficial interest in the entity that is liable tor the property taxes on the pmperty and tha � roperty or s' � ip .un er a contract.
� G!8S0??CQ��':CYfJ_�:.�:�. .
� CONTRACTRECORDED
�f buying on contract, Fee Simple owners name
Recordefs office where contract is recortletl � Recortl number Page
PROPERTY DESCRIPTION
Counry Township Taxing disiriq (ciry, town, township)
Pa� In r /� � � Legaitlescription
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If any portion of the residential structure or Ne lantl not ezceeding one (� acre that imm atety sunounas Nat structure is usetl to produce income, descdbe the use and portion of
Ne property utilized to O�uce income.
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Township County Township
Signatur of Gaimant
�ereby certify the above statements are true, correct and complete.
Address (nu rantl �(reeC\ ci'�y, sta . ZlPCOtle)
W V
ASSESSOR USE ONLY TRUETAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land not exceeding 7(one) acre immediatery (� �
surtounding resideniial improvements.
Otherland (Z)
Total land (line 1 plus line 2) (3)
Dwelling (4)
Residential improvements
Garage (5)
Other improvements (6)
Total improvements (Irne 4 through line 6) � (7)
Total value (line 3 plus line 7) (8)
I hereby certify the above is true, covect, and Signature of Assewr Da[e signed
wmplete.
Veritying action - Signa[ure of Autlitor Date signed
�1 STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _ -
Lesserof 1/2 Homestead S
Valuation or 52.000
SignaWre of Auditor \ Date sign �L`
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