Homestead_ButtsFOHM ML IU 19i9
PresuiGeG By Sta�e BoarO al ia. Commissfoneis
CLAIM FOR HOMESTEAU PROPERTY TAX CREDIT FOR YEAR.19
ta Be FileO in Wo���ate
SEE BACK FOR FILING INSTRUCTIONS
��VVe) �aTT3; C'>4�2otyai ?/�'resset.G� certify that on the 1st day of
arch, 19�, I, (We) occupied as our principal place of residence the following described real property for
which a Homestead Property Tax Credit is hereby being claimed:
I, (We�wned
❑ are buying under contract
❑ have a beneficial interest in the taxpayer
Property Description in �'�s�'-� Cou
Taxing District (City, Town, Township):
Parcel Number
If buying on contract: Owners name ��� s�mo�e e..�e,i
Oo� -Do�ys
IH To
Township
or legal description shown on tax statement:
P,b n1 ��i SE�i.t 3/-/-/o �//. G� i9 �
Contract recorded in Recorders Office - Record No
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 oi the property utilized to produce income
Any other counties in which individual owns or is buying real property: County Township
� `�h e certify the above tement is true, correct and complete
�v� c,E �/.�i
'Signa ure Sveet naoress Cny. S�a�e ano Z�o �e
' Individual either owns or is buying under a conVact that provides he is to pay the property taxes
on the residence, or has a beneficial interest in the taxpayer.
S 3i ]:7 FXY��Y� I:� Y� bY�iP► I�!
Land not exceeding 1(one) acre �nmed ately
surrounding residential�impro�vemepts � �
Other Land � ��
Total Land
Residential Improvements
,.._ � � 107� .
� �
G'�
Other Improveme�ts
Dwelling
/��L�C;:1�rivarage
' AU�ITOR Total
T� Improvements - Line (6) plus (7) equals (8)
I._,_.aby certify the abov� true. correct. and complete.
Approved
True Cash
Value
(1) a`-o 0
(2) So 0
(3) /000
(4) �
(5) —9�,Q—
�s> y�-�-e
(�) �6 Q'/`'�y"�cL
�g) .3L-�$�
�f— y p
� [i 77 [ i P► � e;' /_ i � I � ] i ti ] ; �
Assessed
Valuation
/70
Homestead
Valuation
/70
Date: �� � % 7
FORN
,ppg
PRFSCRIHED Bl' THE DEP.VtTME\T OF LOCAL Gp�'ER,�NE,�iT {y�� E�6��'TS_Ie ;
I individuals and married couples are limited to one homestead standard deduction. As the receipt of this
ed tion becomes more beneficial, there is more incentive than ever for homestead fraud. Homestead fraud
causes higher ta� bills for all; therefore, HEA 1344-2099 requires ta�pay�ers �vho recei��e the homestead
andard deduction to verif�� that they� are eligible to recei��e the benefit and to provide additional identifying
information necessan• to allo�v couoty� go��ernmeut to better monitor homestead filings. This information
vi11 be kept confidential and can onl�� be accessed by authorized county officials. The Department of Local
Go. ernment Fine�CC �Vlll USe this information to create tools that ���ill help counh� officials elimioate
homestead fraud.
Catol}m / Russell Butts
Complere mid r¢trint to:
am�. ,
� lis S-2_l,l
Ma�in9 Add�ess lnart8ec a� street dN. sta;e
V�98 N, S.R. b�
iotlal5ewnry NurtiOU (VSt 5 Elpits)
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rel, dh. ��° aM ZIP cade)
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ALdEIe
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I . ,✓$ameaspopertyaaCresz
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Dnvefs License State 10 N�rtbe� (WZt 5 Elplp) Sus ONg (please sped(y in Part 6 Delow)
����� �
cacn unoersigneo cerunes, unaer penairy or pequry, mac me aoove ano �oregomg mrormauon is we ana correa ana mai ne or sne is eugioie ro recerve �
homestead standard deducfion on this property. Each undersigned also understands that, by daiming additional homestead deductions unlawfully, he or
she may be liable for back tazes and substantlal finandal penalGes. �
� yy�� Date Telephme
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