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Prescribe0 By Siate Bwrd ol Tar CommiSSioner5
CLAIM FOA HOMESTEAD PROPEATY TAX CREDIT FOR YEAR 19 �`�
Ta & Fi1cO in DuDlicate
SEE BACK FOR FILING INSTRUCTIONS �n
� � ��J�_� w�,v.:
�(We) �""`7"""' ��~'''`'t'Q'°�— �' '� ' certify that on the 1st day of
arch, 19.�, ,(We) occupied as our principal place of residence the following described real property for
which a Homestead Property Tax Credit is hereby being claimed: ,
I, (We) ❑ owned �/` �D �O'� ��0�
O are buying under contract
❑ have a beneficial oi�nter,e,st in the taxpayer � �� � "
Property Description in �—�-�-�'^ County —«-�- Township
Taxing District .(.Gii�-Towrr,-�awrtship): �/S • � �'a""'`'�-'
� Parcel Number or legal description shown on tax statement:
���..� J�c�-c-.�.t-�. B � .�
If buying on contract: Owners name ��� sim0�e o.�e��
Contract recorded in Recorders Office - Record No. Page
If any portion of the residential structure or the land, not exceeding one (1) acre that immediately surrounds that
structure is used to produce income, describe the use and portion of the property utilized to produce income
Any other counties in which individual owns or is buying real property:
�hereby certify the above statement is true, correct and complete.
County Township
'Signature " v Sttee( Atlaress Ciry. State an0 21p CaCe
�-�.9-7'�
' Individual either owns or is buying under a contract that provides he is to pay the property taxes
on the residence, or has a beneficial interest in the taxpayer.
- FOR ASSESSOR'S USE ONLY -
Land not exceeding t(one) acre immediately
surrounding residential �a�{m� � �
Other Land 1
Total Land
Residential Improvements ���� "�' �979
�Dwelling
�������2 U Garage
� 4iL.A�L
AUDITOR Total
Other Improvements
Tr,�' �mprovements - Line (6) plus (7) equals (8)
I��oy certify the above is true. correct. and complete.
SignaWre ol
True Cash
Value
(�) 7�0
(2)
(3) % 'io
(4) �
(5) 1'�D
(6) -L�-��e'
(�)
�
Assessed Homestead
Valuation Valuation
����
2 S�
%�-+-� z z,/ 9 7 y
Da:e
- ACTION BY AUDITOR -
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Date: