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4+ �� CLAIM FOR HOMESTEAD PROPERTY TAX
= CREDIT/STANDARD DEDUCTION
'> �: J State Form 5473 (RS / 10-01)
Presfiibed by the Department of Local Govemment Finance
INSTRUCTIONS: See reverse side lor7iling instructions.
�i`'d�..;:.:s�.V< ,=. -. � �. e" . �CERTIFICATIONSTAlEMENT"�-�,
FORM YEAR _I
HC10
5 -I`�(-la
I(VJe) �.. � Ki1 Vi certify that on the 1 st day of March, 20_
I(VJe) occupied as our principal place o( residence the follo� ' �g descnbed real pmpetly tor which a Homestead PropeAy T�c Credit is hereby daimed:
❑ I(VJe) owned ❑ Are buying under wniract
�ve a benefidal interesl in the entiry that is liable for ihe pmperty taxes on the properry and Ihat owns ihe property or is buying under a contract.
cs`"s�c..L3�'c�>r'r�=. .??•_ -'-'s..._..- '�":,Z"�:�CONTRACT'RECORDED'�" - . .
I( buying am m�traa, Fee Simple owners name
Recorders office where contrad is recorded Rewrd number Page
Counry
Tavnship
IP,TION� .-:., ':.: -.."•tt_d:
Aislricl (cily, town, fownshi�
,.-�� •.. ,..
�mper /,1 ^w �� �I Leg�e�yptiq� , . �.J n� I Is the O�operty in puestion:
�y ����r, � - �}{,.,��_�-•� -,�
t v��[,•, li � � t�_,.uc��1.J •°� �J ❑ Real Property ❑ 61abile Hano (l.C. 61.1-7)
i( any portion of the residentlal sWCtura w the land no� exceeding one (1) aae l�al immetliately surtounds �hal structure is used to Droduce income, desvibe Ihe use and portion
af tha proDerty utilized to produce inwme.
�N_-)� // .�. //1/1^
COUOIy
I hereby certiy the above statements are true, conect and complete.
Counry
� �4a1 W � -3 _ } �R. L . . . . _ N �� . . v �
-- s � � �e TRUE?AX - �ASSESSED VA[UE � HOMESTEAD � �+ NON RESIDENTIAL
�-�����-��A�SSESSOR�US�ONLY . _..f.} � ss� VALUE- � �`"AT100%OFTN. r VALUE�y 4.' `42�� <€{.?_..:iVALUE ��/� j i:
Land not exceeding 1(one) acre immediately �.tf�t�'t� �'°'�S �."' t����� `�
��) ',� �, v-s� c:..c �lti.^ '�
suvounding residential improvemenls. „y,�:,.`..; {Y. _�;Y,q,_. i -
Other land (p) . �i'° �� .-._� ' -
.t`,r:..s�:_:
Tdal land (line 7 plus line 2) (3)
,. �„ +� - x .� '.
Dwelling (4) 5 >�-, < f'`5� { � l`i�� �x -. ��
Residenlial improvemenLs � '�'�"' ""S'�" "'z'Sy��,�t" '
Gara9e (5) �._�r� ����' �'��r°�rS��r�.,S�?:-
>`, �a,..;n�r'�.-_w`'"a.,�.c..-,�5 �
,•. �;..:.-Yy�,: .
`.. v-_•.�..
Oiher improvements (6) l' Y..T.i �.:--.-: s
: au,•_..
Ttlal improvemenfs (line 4 through line 6) (7)
Rtal value (line 3 phs line n (g�
I hereby ceAify the above is We, coried, and Signature o(Assessor Date signed
complete.
Verifying actbn - Signawre oflwditor Date signed
20_Pay20_
Lesser ot 7/2 Homestead
Valuatlon or 56.000
S
olAuditor � _ � x n . I Date si9neE