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Presc�i�eA q Ine Sta;e
Boara al ia� Cammissioners
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STATE OF INDIA,,,NnA,
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AFFIDAVIT OF. PERSON, 65 YEARS OF AGE OR MORE ,t _}
REQUESTING PROPERTY TAX DEDUCTION
TO BE FILED IN PENSON OP B1' MRIL EACH YEAN WITH TME '���Q
COUNTY AUUIiOH WNENE OWNEN'S PROVEflTY IS LOCATED:
NEI.L PPOPENTY - BETWEEN MANCH 1 AND MAY 10. INCLUSIVE
MOBILE HOME � BEiWEEN JANUARY t �NO M/PCN �l, INCLUSIVE
(NOT RSSESSEO A$ RE�L VHOGENTY)
(61.14Y-9 AND F1.1-12-10.1)
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COUNTY. SS:
certify that I, (We) was/were
�S �. � -
years of age on th � That I, (We) reside at
�•�•� , OS� ' Township,
�STREET OR RUFAL ROUTE�_ �� (QTY OR TOWN) -�
O ./ l/
/O�^v��� County, Indiana; that I, (We) have owned the following described
I�, real estate
❑ mobile home
for 1(one) year or more prior to claiming this deduction, and That I, (We)
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:
I 1�r I ,[
�gal Description or Key Number p7C ,`� �/y �� /� 3 5�� �'� �. TS � L-
Assessed value of real estate or mobile home as of March 1, current year:
The total annual gross income of this affiant when combined with that of his or
her spouse for the prior calendar year, without any deductions, did not exceed
511,000 and was derived from the following sources and in the following
amounts:
E OF INCOME
� Y��' l�'' ....:........................S
.
t'�-.� � �.� .� . . . . . . . . . . . $
0'�l � ��3� i988 . . . . . . .. . . . . . . . s
� 1 r� (,
TOTAL..S
AMOUNT OF INCOME
v �
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 tie submitted for county auditor's inspection.
, !
nther than a Mortgage or Contraci Deduction, do you receive any other deduction from properiy tax?
`�s NO � Have you filed application for deduction in this County or any other county?
as NO
1 swear under penalty of perjury that the above and foregoing information is true and correct.
`$ee False Statement Penalty Below. (On Receipt)
�Owner's Camplete Aadress�