Homestead_Tretter�E���� �
a/ °{ CLAIM FOR HOMESTEAD PROPERTY TAX
31��( CREDIT/STANDARD DEDUCTION
�.;; State Form 5473 (R2 / 5-92)
� ,.�. ' .
WSTRUCTIONS: See �eve�se side Ior7iling instructions.
/1
I I � � � � � � . CERTIFICATION STATEMENT
FORM
HC10
�/
�(`IJe) _� �/V� f�� LQ�J� certify that on the �T da� of�1�
�) occupied as our principal place of residence the tollowing described real property tor which a Homesiead Property 7ax AUGis hereby dai �
�J I(We) owned ❑ Are buying under coniract � . , � 5 �99I
❑ Have a beneticial interest in the entity that is liable for the pmperty taxes on the pmperty and thai owns the propert is buying under � nirac
� . CONTRACT RECORDED ��g����� ' � - �.�701TI
It buying on contract, Fee Simple owneis . ame. , . .
Recortler's oHite where contract is recorded pemrd numher Page
County
PROPERTY DESCRIPTION
Townsftip . � Taning disvict (dry, fown,
�� �-U(7�/-�U . . .
If any portion of the residential stmcwre or ihe lantl not exceetlirg one (1 � acre that immetliatey surmunds that strucmre is used �o praduce income, descnbe the use afM portion
ot Ne property utilized to produce income. .
Couniy
v�a�i�
PROPERTY OWNED BY
Township
�eby certify the above statements are true, correci and complete.
Address (number and sfreel. dry, state, ZIP mde)
ASSESSOR USE ONLY
Land noi exceeding 7(one) acre immediately
surrounding residential improvements.
Oiherland
Total land (line 1 plus line 2�
Dwelling
Residential improvements
Garage
Oiher improvements
Total improvemenis (line 4 through lina �
Totat value (line 3 p�s line 7�
I hereby certify ihe above is tme, correci, and
complete.
V?rifying aclion - Signa.ure of Autlitor
19_Pay79=
Lesser of 7l2 Homesiead
valyaiion or 52.000
TRUE TAX
VALUE
(�)
(z)
(3)
(4)
(5)
(6)
l�)
(8)
Siqnature ofASSessor
paJ
ASSESSED
VALUE
DEDUCTION ALLOWANCE
E
HOMESTEAD
VALUE
NON-RESIDEN'fIAL
VALUE
Date signetl
Date signed
�netl
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