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Form 3D PeviSea 19PA AFFIDAVIT OF PERSON� 65 YEARS OF AGE OR MORE
Prescn0e0 try I�e Sta�e
eoam oi ra. comm�ssioners REQUESTING PROPERTY TAX DEDUCTION
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STATE OF INDIANA,
TO BE FILED IN PEfl50N Ofl 8Y MAIL E/CH YEAR WITH THE
COUNTY AUDITOP WHERE OWNER'S FFOPEHTY IS LOC/TED:
FEAL FFOVERTY - BETWEEN MARCH 1 AND MAY 10. INCWSIVE
MOBILE HOME - BETWEEN JANUAp1' 1 4ND MARCH ]1, INCWSIVE
(NOT ASSESSED AS FEAL PROPERTY)
I.ND bl.l4]40.1)
COUNTY. SS:
I, (We) � � � � k�.� (�,��A- , certify that I, (We) was/were
��—years of age on the � �. Thaf I, (We) reside at
� �3 �� � a.� , �i.n� , �1' 1� Township,
�STREET OR RUFAL FOUTE) 1 1 TY OR TOWN)
�J� *^^ � County, Indiana; that I, (We) have owned the following described
✓�11 �
�B'real estate
for 1(one) year or more prior to claiming this deduction; and That 1, (We)
❑ mobile home
now reside in the premises for which this deduction is claimed:
Surviving Spouse: If application is being made by a surviving unremarried spouse:
Spouse's age at time of death:
Name on property tax records if different from above:
Legal Description or Key Number: �� • N� �%' a`�� �• �g A L
�'^3
sessed value of real estate or mobile home as of March 1, current year. �g� �1�� �� �sr�—
•��
Were either you or your spouse required to file an income tax return for the preceeding year? Yes �
No If yes, a copy of such return must be submitted for county auditor's inspection. _
Other than a Mortgag� Contract DQduction, do you receive any other deduction from property tax?
s NO �kiave you filed application for deduction in this County or any other county?
�s NO `�
I swear under penatty of perjury that the above and foregoing information is .true and correct.
'See False Statement Penalty Below. (On Receipt), ..
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