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16
GLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Fortn 5473 (R2 / S92)
INSTRUCTIONS: See �everse side lor filing instructions.
FORM YEAR
HC10 �
�!'� � � A� w�r
RTIFIC TION S ATEMENT -
I(We) � certi at on the 1 st da f March, 19_ -
I(We) occupie as our principal place f esidence the following ribed real property for which a Homestead operty T�x C_1�dit ereby ai
❑ I(We) owned ❑ Are buying under contract , ���°'�}
G,�S!',�;::.�:,i�: 'UDITOR
❑ Have a beneficial interest in the entity that is liable for the property taxes on the property and that owns the property or is buying under a contraci.
� � - CONTRACTRECORDED � �
If buying on contract, Fee Simple ownefs name
Recordels oKCe where contract is recortletl Aecord number Page
PROPERTY DESCRIPTION
Counry _ Township Tauing distnct (city, town, township)�
P rcel number Legal descnpiion
- 30-3— D
If any portion of Uie residential struciure or the land not ezceeding one p) acre that immediatety sunounds that strucmre is used ro pr uce income, tlescnbe the use antl portion of
the pmperty utilized m produce incrome.
� �9-.30-5�-6a�.c�3-c���
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Township _ . Counry Tormship
Sign ure of clai an�
��ereby certify the above statements are true, correct and complete: c
Address (numbe� and street, city, state, ZIP wde) -
(� 2 a�,,� s iu.l i- � nl Gl 9�y39-
ASSESSOR USE ONLY TRUE TAX . ASSESSEO HOMESTEAD NON-RESIDENTIAL
_ VALUE VALUE VALUE VALUE
Land not ezceeding 1(one) acre immediately (� � � .
surrounding residential improvements.
Otherland (2)
Total land (line 7 plus line 2J (3) - .
Owelling (4) . � -
Residential improvemenis
Garage . (5)
Oiher improvements � (6)
Total improvements (line 4 through line 6) (7)
Total value (line 3 plus line 7) (8)
I hereby certi(y the above is true, cortect, and SignaWre of Assesor Date signed
complete.
Ventying action - Signature of Autlitor Date signed
STANDARD DEDUCTION ALLOWANCE
19_ Pay 79 _ �
Lesser of 1/2 Homestead c�
Valuation or 52,000
Signature of Auditor Date s (7'�
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