Homestead_Graper (5)r; CLAIM FOR HOMESTEAD PROPERTY TAX
' CREDIT/STANDARD DEDUCTION
t � State Form 5�73 (R6 / 403)
Prescribed Dy Ihe Department of Local GovemmeN Finance
INSTRUCTIONS: See revcrx sidc loi lifinq insfn�clions.
�-: •- t . :-r. , .r: _ "
FORM �` YEAR
HC10 �
:..,:?3�: .*`.:1, .n _ �)n. , � . � �.. CERTIF ATtONSTAlEMENT'. - -_ � _.. .� � A�c"'�J�1L/ 1.�
I(We) hat on the 751�da�'ot�1$cF�(��
I(We) occupied as our principal place of residence lhe ( wing descnb real property for which a Ho es�ead Property Tac Credit is hereby Gaimed:
❑ I(We) owned ❑ Are buying under contract --�d� ��
� Have a benefidal interest in the enUry that is liable (or the property taxes on the properry and that owns the pwperty or is buying ifafler a c r,t„
If 6uyinq om m�Vad. Fee Simple owners name
Remrdefs olfice whera conUaq is remrded
Record num6er � Page
.. ... . �� . .. ._. -.. .. _a: :. � � '�
�n Tawnship T�cing ai5lricl (ciry. (own. ow hiP)
Pe�o �/ O� �� Legal descnption Is the pro question:
eal proDerty ❑ Mobile Homo (I.C. 67.1-7)
I( any portion ot the resiCentlal strucwra a Ne land not exceeding one (7) acre that immetliatety surtounds that sWCture is usetl to protluce inwme, desuiba the use antl ponion
of Ne property utilized m produce inwme.
- / �-�a -�1�� - �/. oG2 o�s
County Toxnship Couniy
I hereby cerGfy Ihe above slatements are W e, correct and complete. SIg ture ot claimant
L
A�dm�� (number and street ury, sfate, ZIP code ,
"� ' R R d t�oX /du, �/�nc-�{n� , �'N '-f�7(o70
�
� �
-t+tr�'�'-a "t"� �,TRUETAX ASSESSEDVALUE .�HOMESTEAD'` NONrRESIDENTIAL,.
, =a < q y� ` �
;q. x�**iy s�s .�-_ASSESSOR-0SEONLY - . -�'. VALUE AT 100%`.OFjTTV' 'sF."' VALUE�":".� ' ::�.�VALUE'>
.. ..:- �� ., �
_.,?�`F ,e.� .,_... .�+,.. .s.� ._ ... . ,- . ,_ -�.
Land not exceeding 1(one) acre immedialely -�+ � ''"` '�"': .".
surrounding residential improvements. (�� . , � . � �
Other land (Z� - � ,
Tdal land (line 7 plus line 2) (g)
Dwelling (4) .� -
�r ;�}' _ r,...: .
Residential improvements or Mnually vy` �:: _
Assessed Mobile / ManufacNred Home Garage (5) . �
3:�3• ... ,_... ...
Other improvements (6) �
Tclal improvemenLS Qine 4 fhrough line 6) (�� �
TUaI value (line 3pha line � (g)
I hereby certify the above is We, conecl, and signawre o�nssessor oa�e signed
complete.
Venfying actbn - Signature of PLditor Date signetl
20 _ Pay 20 _
Lesser of 12 Homestead
vamauon or 535.000
S
'. ' , •
r�
� • � �
��:�i�