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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Fortn 5473 (R2 / S92) �
FORM
HC10
YEAR
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INSTRUCTIONS: See reverse side lorliling instructions .
� CERTIFICATION STATEMENT p
I(VJe) �rcertify tha/t/on the tst d of March, 79_
I(We) cupied as our principal place of residence the following described real property for which e o estead Prope.cFy Taz dit hereby claimed:
❑ I(We) owned ❑ Are buying under contract /� .�..+�� �''� �p�TpR
❑ Have a beneficial inierest in the entiry that is liable for the property taxes on the property and"th�s�the�property or is buying under a coNract.
CONTRACT RECORDED �
If buying on conVact, Fee SimD�e ownefs name �
RecorCels of(we where conVact is recorded _ Record number Page
PROPERTY DESCRIPTION .
Counry Tovmship Taxing district (ciry, town, famship)
Par I number Legal descnption � �)`
� V
If a rtion of ihe reSiAentla or Ihe IaM �rot exceetlir�g oPe (1) acre Ihat immedia[ely surto n 5 thai SWCture is usetl to pr uce income, describe Ihe use and poNOn of
ihe property utilizetl to protluce income. �,�
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PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Towns�ip Couniy Township
Sig [ure ot d imani
•ereby certify the above statements are true, correct and complete.
Addr (numbera�MSbeet,ciry,s7ate,ZlPCade)
7� N Ken�weo ' �PAr�CN, lN.'F�b�F
ASSESSOR USE ONLY TRUE TAJ( � ASSESSED HOMESTEAD NON-RESIDENTIAL
- VAWE VALUE VAWE VALUE
Land not exceeding t(one) acre immediatery � (�� . �
surrounding residential improvements.
Otherland (2)
Total land (line 1 plus line 2) (3)
� Owelling (4)
Residential improvements
Garage (5)
Other improvements (6)
Total improvements (line 4 through line 6) (7)
Total value (line 3 plus line 7) (8)
I hereby Certify the above is Irue, correCt. and Signamre ot Assesor Date signetl
complete.
Ventying action - Signamre of Autlitor Date signed
� STANDARD DEOUCTION ALLOWANCE
19_ Pay 19 _
Lesser of 1/2 Homestead r�
Valuation or 52,000
Siqnature ol Audimr Date signetl