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PreuriCeO By SUte BoarC ol Ta� Commissioners
CLAIM FOR HOMESTEAD PROPEATY TAX CREDIT FOR YEAR 19 �9
To & FIW in Duplirare
SEE BACK FOR FILING INSTRUCTIONS /y /� �Si�q��
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�(We) ���r�� �� �-�-^-�� certify that on the tst day of
arch, 19 '� I, (We) occu ed as our principal place of resi nce the following described real property for
which a Homestead Property Tax Credit is hereby being claimed:
I, (We) � owned
O are buying under contract
❑ have a beneficial interest in the taxpayer
_ Property Description in �� County �^� Township
Taxing District {$i[�Town;�ewnship): �� �Z-a—.^-<-�-
Parcel Number or legal description shown on tax statement:
�� . / g,b.� . / 9 E �i d � � �%
If buying on contract: Owners name �'� �""v'e °""ef�
Contract recorded in Recorders Office - Record
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: County Township
hereby certify the above statement is true, correct and complete.
�
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'SignaWr Sveet AOCress Ciry. Stare ana 2io �e
' 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 1 (�Ae) �cre �med�ly �
surrounding residential��t�:pr eme ts
Other Land
Total Land
J Ut� 12 1979_
Residential Improvements
�,,,��� / ,/(��� ��welling
, �r � =�a�i�u�arage
t�� AUDITOR Total
Other Improvements
T�'-' Improvements - Line (6) plus (7) equals (8)
I��oy certify the above is true. correct, and complete.
Signawre ol Assesmr
APP
(�l
(2)
(�)
True Cash
Value
�".�.
Assessed
Valuation
�
370
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- ACTION BY AUDITOR -
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Homestead
Valuation
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Date: