Homestead_Rose (3)����" - CLAIM FOR HOMESTEAD PROPERTY TAX
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` CREDIT/STANDARD DEDUCTION
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� Slate Fortn 5473 (R2 / 692)
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INSTRUCTIONS: See reverse side !or liling instructions. � t� � v LOOO �
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CERTIFICATION STATE NT ' . �i:� �
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I(We) T certify thai on the 1st day of March, 19_
I(VJe) occupie s our principal place of residence the follo i g described real property for which a Homestead Property Ta�c Credit is hereby claimed:
�] I(We) own ❑ Are buying under contract '
�] Have a beneficial interest in the entity that is liable tor the property taxes on (he property and that owns the property or is buying under a contract .
CONTRACTRECORDED
It buying on contmct, Fee Simple owners name -
Recordets oHice where contrnct is recorded � . Record number . Page
PROPERTY DESCRIPTION
County Township Ta�dng di irict (ciry, town, mwnship) '
Parcel number Legal tlescription
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It any poNon of the residenfial sWCNre or ihe lantl not exceeding one (1) acre at immetliatey surtountls that swcture is used to produce incrome, descnbe the use antl portion of
Ne property utilized to protluce incame. �
�-/ 9- a9-,3o0 - c�/. 49� a�.S
� PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Townsttip Counry Township
Si ature of claimam
�ereby certify the above statements are true, correct and complete. o �
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AOtlress (number and street, ciry, sfa(e, ZIP code)
ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land not exceeding 7(one) acre immediatery (�) -
surrounding residential improvements.
Otherland (2) �
Total land (line 1 plus line 2) (3)
Dwelling (4)
Residential improvements
Ga2ge (5)
Other improvements (6)
Total improvements (line 4 fhrough line 6J (7)
Total value (line 3 plus fine 7J (8)
I hereby certify the above is true, correct, and Signawre of Assewr Date signed
complete.
Veritying action - Sgnamre of Autlitor Date signed
.�� STANDARD DEDUCTION ALLOWANCE
79_ Pay 19 _
Lesser of 1/2 Homestead 5
Valuation or 52,000
Signature oi Auditor Date signetl