Homestead_Rose�, CLAIM FOR HOMESTEAD PROPERTY TAX
' CREDIT/STANDARD DEDUCTION
Slate Fwm 5773 (R6 / 4-03)
Presaibed by ihe Departmenl of Local Govemment Finance
INSTRUCTIONS: See reverse side /oi (iling insVUCtions.
FORM 1'EAR
HC10
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I(VJe) 7v1/(�.1�/1U �i�- (�'��/3/(.i/ (� `r� �oi �' certify thatl�the tst day of March, 20
i
�e) occupied as our principal place of residence the foliowing described real property for which a Homestead PropeCy�Tac Credit�is hereby dai d:
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I(We) owned ❑ Are buying under contract �O Gi5SOt CJ Oi1N�;,���TO^
Have a benefidal interest in the entity that is Iiable for the property taxes on the property and that owns the property or is buying under a contract. f
If byvig on contaq, Fee Simqe ownefs name
Remrders ofice whara mniraq is recorded
Coun �/ Township Tacing dis ' t � , town,
Parcel w r e' i Is Ne property
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If any poAion al the residenllal sWCWra w the land not exceeding one (1) aue ihat immediatety wrtounds ihat s<
of the property utilaed fo produce incoma. ��� ��
County
- /�' o?d'-/�O -0"Gb, 7o3G -
To.vnship
I hereby certi(y ihe above statements are W e, corred and complete.
County
�
Record number
Page
�quesfion: /
Real Droperty ❑ Mobile Homo (/.C. 67.7-7)
ire is used to produce income, desaibe the use antl poNon
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'�" S'f,A E„S �RUSEONLYL, daz�-��,4. ��YTRUETAX��� ASSESSEDVlLL.UE �HOldESTEAD�z ' �e�NxON'-�yRESf�ENTIAL �
����,��;;�{�_.��,_„�'�� �� VALUE �'� rATy100°k'OF'T.N VALUEf' 4;' VALUE't ����,
�._ ...i -ss..x:.-.2::i"`'GS.,,...�...e����_.l...r....�:,i�.�..
Land not exceeding 1(one) acre�immediately � �.{�S��T`� ��;�
surrounding residential improvemenis. ��) `���{ �T�- r �'
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Other land (2) i`�`"��[���,'rt� . -
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Tdal land (line 7 plus line 2) �3)
-r+, ra �i��
Dwelling (4) .s.� e��: f'3`
Residential improvementa wMnualty '��'F'i4 � �-' ���--� y
Assessed Modle / Manufacturad Hane Garage 5 l��,`,i� ., ' "�h
( J �,.���� � �'t�:'��
asa� '?�-�i'�`�i
Other improvements (6) � �i �
�r�Y£�
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Total improvements (line 4 fhrough line 6) (�)
T�ial value (line 3 plta line � (g)
I hereby certify the above is We, coved, and Sgnamre otPssessor Date signed
complete.
Vrrilyifg action - SignaNre oflwdilor Dale signed
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.r., -o-�'-.�:�"'7ag?�i-+'e�',�e�'����s�f��:�STANDAR�'.-0EDUCTIONALLOWANCE'�y?.�:y+ �..tr,�v.^'-ts�z i�!�- .�^'„',�.a��_��',�3"�.°.'.�«'��r�.F�.%rf
20_Pay20_
Lesser of 1/2 Homestead S
� vauauon or E35,000
SgnaWreofAUdrtor � ' Datesigned