Homestead_Elpers (5)Wflht HC 10 19i9 Be FileG in Duo�i��
heuriGeE By State Boara ol ia, Cammissfoners — ,��/
CLAIM FOR NOMESTEA� PROPERTY TAX CREOIT FOR YEAR lg U �J`��
SEE BACK FOR FILING INSTRUCTIO
/ I' ,, '
(We) �!/�! ��n�.�QL� �Q%A certify that on the tst day of .
J�arch, 19 � I, (We) occupied as our principal place of resid nc�wing described real property for
which a Homestead Property Tax Credit is hereby being claimed: -
I, (We) LV'owned ��"��O?-S �:��—��1J-7�'3� ��
❑ are buying under contract
O have a beneficial interest in the taxpayer
Property Description
Taxing District (City, Town, Township):
Parcel Number �
If buying Ofl contract: Owners name ��� simD�e owneq
Township
or legal description shown on tax statement:
1
L
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.
avee� naoress
County Township
ury. a.ace ano uo �.oae
' 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(one) acre immedialely
surrounding residential improvements
Other Land
Total Land
Residential Improvements
True Cash
Value
.� � s
(2)
�s� a o 0
Dwelling (4)
Garage �5�
Total (6)
Other Improvements (7) 0.0
�Improvements - Line (6) plus (7) equals (8) (a) �
I-,�ereby certify the above is true. correct. and complete.
Sigremre ol nssessor
- ACTION BY AUDITOR -
Assessed
Valuation
i � �
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l30
a �{ o 0
oa:z
Homestead
Valuation
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