Homestead_Chamberlain�F O
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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION '
State Foim 5473 (R2 / S92)
fORM
HC10
YEAR
IIVS� I HUG I/UNS: JBB lEVBlSB SIOB !OI l/llll(f Il157NC710lIS.
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CERTIFICA ON 5T E ENT +� g,e >. �
I(W ' �� tf� 7st aBy.At March, 19_
I(We) occupied s our principal place of residence he following described real property for which a Homestea�roperty Tax Cre� is hereby clai ed:
❑ I(We) owned ❑ Are buying under coniract /
❑ Have a beneficial interest in the entity that is liable for the property taues on the property and that owns the.property o`r�is birying�G aeca�cen act.
n:.<.:��-;:1 ��;.i;1TY A��iiv�, �S
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CONTRACTRECORDED � �
If buying on contraa, Fee Simple ownefs narne �
Recorders oNke where contract is recorded Recortl number Page
. PROPERTY DESCHIPTION
Counry . Township Tacing is[' t(ciry, fown wnship)
Parcel num . Legal descnpfion
�-o�aa3;� r.J -3- � c.
It any poNOn of the resitlential sirucW re or ihe land not e:ceetling one (1) acre Ihai immediatey sunounds that sVUCture is usetl to protluce income, describe Ihe use and ponion of
Ne propeM utifized to produce income.
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-/9-�9-� a- c�/.�as-o�s'
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Township � Counry � Towns�ip
5 a e of laimant
�..�ereby certity the above statemenis are We, correct and complete. `
Address (numberantlstreet, ciry, stafe. ZIPCWe)
�2 �x �i�-1 � �� . PJrc�,�L�� Tr�! ��l ��-�
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTiAL
VALUE VALUE VALUE VALUE
Land not exceeding t(one) acre immediately (�)
surrounding residential improvements. � �
Otherland (2) .
Total land (line 7 plus line 2) (3)
Dwelling (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 true, correct, and Signawre of Assewr oate signed
comp�ete.
Verifying acUOn - Si9nature ot Auditor Date signed
.r� STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _
Lesser of 7/2 Homestead r�
Valuatio or 52,000
Signat re uditor Date siqney� I� _O �
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