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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT/STANDARD DEDUCTION
SWte Fortn 5473 (R2 / S92)
FORM
HC10
YEAR
OD p/
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INSTRUCTIONS: See reverse side /or liling instructions. ;�
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CE TIFICATION STATEMENT " ��i A
I(We) T� �` v - certily���°py� 1�� of March. 19_
I(We) occupied as our princip I
❑ Have a beneficial interest in the entiry that is liable for the property tazes on the property and ihat owns 1� a Mract.
! TY qUDITOR ,
CONTRACTRECORDED
It buying on contraci, Fee Simple owners name
Recorders ottice where conVact is recorded Record number Page
PROPERTY DESCRIP ON
Counry Tovmship Tazing ' t' (ciry,�own, lownship) -
Parcel num r Legal tlescnption
o� — � 0 � � ' . .
If any portion ot Ne resitlentia� suucture or the IaM noi exceeding one (1) acre ihat immediatey surtounds thai swcture is used to produce income, describe the use and poNOn ot
the property utilized to produce income.
- - a _ - �/. oGs-� s
PROPERTY OWNED BY CLAIMANT IN OTHER COUNTRIES
Counry Township Counry Township
Signature d � t ^
�ereby certity the above statemen:s are irue, correct and complete. ��/
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Address (numberantl sireet, dry, srate, ZIP code)/ �./
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ASSESSOR USE ONLY TRUE TAX ASSESSED HOMESTEAD NON-RESIDENTIAL
VALUE VALUE VALUE VALUE
Land not exceeding 1(one) acre immediately (��
surtounding residential improvements. .
Oiherland (2)
Total land (line 7 plus line 2J (3)
Dwelling (4)
Residential improvements
Garage (5) �
Oiher improvemenis (6)
Total improvements Qine 4 through line 6) (7)
Totai value (line 3 plus line 7) (8)
I hereby certify Ihe above is true, correct, and Signamre of Assewr Dace signed
complete.
Veritying actian - Signature ot Autlimr Date signetl
STANDARD DEDUCTON ALLOWANCE
19_ Pay 19 _
Lesser of 1/2 Homestead �
Valuation or 52,000
Signature of Audimr Date signed