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NeuribeA By State BoarO of 7az Commissianers
CLAIM FOR HOMESTEAO PROPERTY TAX CREDIT FOA YEAR 19 ��.
To & FIeA in DuD�icate
SEE BACK FOR FILING INSTRUCTIONS ��` �a i// l�Oa
y'CO ��
. I, (We) �� ��- �' certify that on the 1st day of
, arch, 19��, I, (We) occupied as our principal place of residence the following described real property for
t�,ich a Homestead Property Tax Credit is hereby being claimed:
I, (We) O owned a�p -�9 07`� �-�.�5 -(/oZ �
- ❑ are buying under contract
❑ have a beneficial interest in the taxpayer
Property Description in �-�--�-n— County
Taxing District (City, Town, Township):
Township
Parcel Number or legal descrip�on shown on tax statement:
�� � E ��5� � `� - �f - � o / Q.�. .
If buying on contract: Owners name "� Binp1e °""ef�
Contract recorded in Recorders Office - Record
If any portion of the residential structure or the land, not exceeding one (1) acre that immediately surrounds that
structure is used to produce income, describe the use and portion of the property utilized to produce income
Any other counties in which individual owns or is buying real property:
I hereby certity the above statement is true, correct and complete.
[�l`�Rn
���
County
Township
Ury, state ana [�o �e
Individual either owns or is buying under a contract that provides he is to pay the property taxes
on the residence, or has a beneficial interest in the taxpayer.
- FOR ASSESSOR'S USE ONLY -
Land not exceeding 1(one) acre immediately
surrounding resitlential improvements
Other Land
Total Land
Residential Improvements Dwelling
" Garage
Total
Other Improvements
Total Improvements - Line (6) plus (7) equals (8)
I hereby certify the above is true. correct. and complete.
SigndNre o� A55¢SSOr
(t)
(2)
(3)
True Cash
Value
,�o 0
So 0
c4� /98z�
(5) —
�s> /98�
(�) —
(8) � 9 8 zo
- ACTION BY AUDITOR -
Assessed
Valuation
/70
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Date:
Homestead
Valuation
/70