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CLAIM FOR HOMESTEAD PROPERTYTAX
CREDIT/STANDARD DEDUCTION
State Fortn 5173 (R6 / 1-03)
Pre�aiDed by the Departrnein d Lxal Govemment Fmmke
� INS7RUCTIONS: See ia�0/i9 dda Mf$p ittOl�torla
�� YEAR
FORM �
HC10
I(We) � \ Vi certify thatvn tlie-1st dey.W Ma c�,120_
I(We upi s our prinGpal place oi residence the following ' d real property for which a Homestead Prope T�c Credit is hereby daimed:
I(We) owned ❑ Are buying under contrect N�� 2 1 2005
� Have a benefidal interesl in the entity that is liable for the property taxes on ihe property and that owns lhe properry or is buying under a contraU.
II buying om m�Vacl, Fee Simple owners name
Remrdels ofice whera conVad is recorded
County
Tovnship
Tacing
Recoid number � Paga
rw� -
r A �'j7 Legal description s ihe property in Ques' n:
LJ �✓ 0 eal D�operty ❑ Mobile Momo (/.G. 67.1-7)
II any portion of Ihe resitlential sW qure or Ne land not exceeding ona (1) acre lhel immetliatety surtounds that sW cture is used b Droduce incwne, desaihe Me use and portlon
ot the properry utiizeA b produce income.
Toxnship
I hereby certify ihe above statemenls are W e, wrted and complete.
r
tddresy,(num6eiaMSVee4city,sfafe,ZlPcodq) � , .
Land not exceeding 1(one) aae immediately
surrounding residential improvemenis.
Other land
Tdal land (line 7 plus line 2)
I�)
(Z)
(3)
Dwelling (4)
'Residential fmprovements wMnuaOy
Aaseased MohBe / Ma^ufacNred Fimie Garage �5)
Other improvemenls
Tdal improvements (line 4 fhrough line 6)
'al value (line 3 plts line n
I hereby certify fhe above is We, corred, and
complete.
veilying adion - signature orPLaitor
Sgnatwe oflwddor
20 _ Pay 20 _
Le�ser W 1!2 Homestead
veivaLOn or 535.000
(6)
��)
IB)
SignaNre of ASSessor
County
$
daimant
Date sgned
�ate signed