HomeMy WebLinkAboutAge_JordenFOtn 323 flNi5C0 1981
PresribeC by p�e Sta�e
Boare oi iaa Commisswners
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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE
REQUESTING PROPERTY TAX DEDUCTION
TO BE FILED IN PERSON OR BY MAIL EACH YEAR WITH THE
COUNTY AUDITOR WHERE OWNER'S PROPERTY IS LOCATED:
REAL PROPERTY BETWEEN • BETWEEN MARCH 1 AND MAY 10, INCLUSIVE
MOBILE HOME - BETWEEN JANUARY 1 AND MARCH 31, INCLUSIVE
(NOT ASSESSED AS REAL PROPERTI�
(b1.1-12-9 AND &1.1-12-10.1)
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STATE OF INDIANA, �/-�-�.-a-�� COUNTY, SS:
I, (We) , certify that I, (We) was/were
�_years of age on the �/� ? TFiat I, (We) reside at
� 2 , ��a�— , �� � Township,
(Street or Rural Route) (Ciry or Town) ��
�..C=-e�— County, Indiana; that I, (We) have owned the following described
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L� real estate for 1(one) year or more prior to claiming this deduction, and that I, (We) now reside in
❑ mobile home
the premises for which this deduction is claimed:
Surviving Spouse: If application is being made by surviving unremarried spouse:
Spouse's age at the time of death:
Name of property tax records if different from above:
Legal Description or Key Number: �� �/�iiV .� �- �- io %. / 3 y� �Ic'
estate or mobile home as of March 1, current year: `�z �— 5� 3 3 O
���`�Th\ {�I annual adjusted gross income of this affiant when combined with that of
� is�r er use for the prior calendar year, did not exceed $10,000 and was
��Q.� �eriv � �the following sources and in the following amounts: _
��� ; OF INCOME AMOUNT OF INCOME
.. ��, F�- p, -
� . . S-S $
��. .....................$ 3�S's .�s
. . . . . . . . . . . . . . . . . . . . : $ 5` 7 6 s� . _.
TOTAL ...$
Were eithe 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.
ther than a Mortgage Deduction, do you receive any other deduction from property tax?
es No �/ . . -•
ave you filed appiication for deduction in�this•county or any other county? Yes , No '� .
I swear under the penalty of perjury that the above and foregoing information is true and correct.
'See False Statement Penalty Below. (On Receipt)
,
'LLw.�,.. � l� �.c.,i-.
FNed By: � Address
�
On Behalf Of: (Owner's Full Narr .)
(Owner's Complete Address)
Phone No.
I