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CLAIM FOR HOMESTEAD PROPERTY TAX
CREDIT /STANDARD DEDUCTION
^y State Form 5473 (R4I 8-00)
INSTRUCTIONS: See reverse side for filing instructions.
TA
FORM YEAR
HC10
I (We) Y V • \ 1 / �W L certify that o`n the isf day —0Nd ctr 20_
I (Vote pi as our principal place of reside the following described real property for which a Homestead Pro i rebyl laimed:
v 28
I (We) owned ❑ Are buying under ntract / -
Slave a beneficial interest in the entity, that is liable for the property taxes on the property and that owns tlropeAy_o is/b y y{'underp%ont-
apt NTR ACTRECORDED:,.Y,ti- ti/_-`/�" .�3�. "z•'a!�"`.z2- ;-
If buying on contract, Fee Simple owners name
Recorders office where contract is recorded Record number Page
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-1 �,y�t'�'�`'�PROPERT'aD_ E_ SCRIPT _ N��;�� -. "'_,`a�r_- -
county
Township Taxing d
� wnship)
Wunu r
Legal description
If any portion of the residential structure or the land not exceeding one (1) arm that immediately surrounds that structure is used to produce income, describe the use and portion
of the properly utilized to produce income.
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County Townshlo
County Towns hip
hereby certify the above statements are true, correct and complete.
�.jON'- RESIDENTIAL
Sig u f daipr
cress (number and street city, state, ZIP ej -�/ -
I -. o EE A CIS ,'o -; V, q71
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-`-�
LIE'
RrV�il•A.T700Yo
ASSESSES D VALUE
�ffHOMESTEAD
�.jON'- RESIDENTIAL
.�zESSOR'US.NLY rt= .�
OF,2TifY,�,eVAL�E�,t3Vy;pLUE
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Land not exceeding 1 (one) acre immediately{
(1)�,'•wtr
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surrounding residential improvements.
Other land
-
(2) -
ggp
f `M'.
-
Total land (line 7 plus line 2)
(3)
Dwelling
(4)
gg- rgaxm9 p-
r '*�'^, --t
Residential improvements
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Garage
(5)
, - _ ..
, -'.#1
Other improvements
(6)
m
Total improvements (line 4 through line 6)
(7)
Total value (line 3 plus line 7)
(S)
hereby certify the above is true, correct, and
Signature ofAssessor
Date signed
complete.
Verifying action - Signature of Auditor
Date signed
,, ff TAN bA96 DEDUCT ION "ALLO WA- NCE9?' �? y - ;,,• ;, i y i?.
s .a,rr
20 _ Pay 20 _
Lesser of 12 Homestead $
Valuation or $6,000
SignatureofAuditor QQ I Date 77- .-O /