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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
State Fortn 5473 (R2 / S92)
INSTRUCTIONS: See �everse side lor filing instructions.
FORM
HC10
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� C IFICATION STATEMENT �
I(We � certify thai on the 1 st day of March, 19_
I(VJe) pied as our principal place of residence he following described real property for which a Homestead Property Tax Credit is hereby claimed:
I(We) owned ❑ Are buying under contract
❑ Have a beneficial interest in the entity that is liable for the property taues on the property and that owns the property or is E; yh�,q�under.a coniracti '
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CONTRACTRECORDED �` `"'"-���f:'.
If buying on conuact, Fee Simple ovmefs narne �
. M:1Yic)19
Recordefs oH'ce where contract is recortletl ReFo'rC numDer Page
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� PROPERTYDESCRIPTION �O CIRSn:.:.���'.`..'�c�-"�""`"fs"`����
Counry Township Taciig district (ci , t , fownship) - � ' - � � � � •
r oo O(^o Legal tlescription
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If any ponion of ihe residentiai structure or Ne land not exceeding one (7 ) acre thai immetliatey surrountls IDat structure is usetl ro produce income, descdbe Ne use and portion of
the properry uGiized ro protluce income.
a� - 9 �i- �o - �oa. �i- aas
PROPERTY OWNED BV CLAIMANT IN OTHER COUNTRIES
Ii:ounry Township Counry TownShip
Sign ture of Gairttani
I hereby certify the above statements are true, correct and complete. `j� \oyy� �
Ad ess (numberan�street, dry, state, ZlPCnde ��i �
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ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VAWE � VALUE VALUE VALUE
Land not exceeding 1(one) acre immediatety (��
surrounding resideniial improvements.
Otherland (2)
Total land (line 7 plus line 2) (3)
Dwelling (4)
Resideniial improvements
Garege (5)
Other improvements (6)
Total improvemenis (line 4 through line 6) (7)
Total value (line 3 plus line 7) (8)
�reby certi(y Ihe above is Irue, correct, and Signature of Assewr Oate signed
plete.
Ventying ac6on - Signature of Auditor Date signed
- STANDARD DEDUCTION ALLOWANCE
19_ Pay 19 _
Lesser oi 1/2 Homestead 5
V luation or 52.000
SignaNre ot Audiror'7_ Date etl
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