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F^�^ �z+ p=^sm »o AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE
hucriXU Ey Ne State
aaam m ra. co�,r,��n: REOUESTING PROPERTY TAX DEDUCTION
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STATE OF INDIANA,
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—Ll—years of age on
�I estate
❑ mobile home
i0 BE FILED IN PERSON OF BY MAIL EACH YEAH WITH THE
COUNTY RUOITOR WMENE OWNER'S PNOiENTY IS LOCATED:
REAL PROPERTY - BETWEEN MARCH t AND MAY 10. INCLUSIVE
MOBILE MOME - BETWEEN JANUARY 1 AND MARCH Jl, INCLIISIVE
(NOT /.SSESSE� AS PERL PNOGEPTY)
(61.142-9 ANO 61.142-10.1)
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(We) was/were
Thaf.l, (We) reside at
Township,
Indiana; that I, (We) have owned the following described
for 1(one) year or more prior to claiming this deduction, and That I, (We)
now reside in the premises for which Ihis 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: �� �
�gal Description or Key Number: V� • MD � 3 �–) � ' 3, �� C /
r,ssessed value of real estate or mobile home as of March 1, current year: �� �0� �6 ��p3�
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:
SOURCE OF INCOME
AMOUNT OF INCOME
�-.-�w.,� .............................s ��6�:-a.�-�-
............................. S -
�� �-� .............................5 -Fl
TOTAL. .S � �� I • �U�
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 � A
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Other than a Mortga�r Contract Deduction, do you receive any other deducti f ?:'
�s NO �Have you filed application for deduction' in this County or any other county?�f-�s.
s No - APR 2 01990 .
I swear under penalty of perjury that the above and foregoing information is true corre�
'See False Statement Penalty Below. (On Receipt) �D���S ,
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