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form 323 Rer'seG t981
PoexnEea by tne Sa�
BoarG ot Tar Lommissioners
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STATE OF INDIANA,
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AFFIDAV OF PERSON, 65 YEARS OF AGE OR MORE�-,� '�
REQ STING PROPERTY TAX DEDUCTION Ct(1tJ�
TO BE ED IN PERSON OR BY MAIL EACH YEAR WITH THE //J ,�
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�
(61.1 •12-9 AND 61.1 •12-10.1)
SS:
that I, (We) was/were
� years of ag2 on the� ��. That I, (We) reside at
#� /����-�"r�n- ��� , z(l Township,
(Stre or Rural Route) (City or Town)
, Indiana; that I, (We) have owned the following described
�" 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:
'/.� 71,�.0
��
value of real estate or mobile home as of March 1, current year: a%o -/ / 70 =/ l��p .
The total annual adjusted gross income of this affiant when combined with that of
his or her spouse for the prior calendar year, did not exceed $10,000 and was
derived from the following sources and in the following amounts:
SOURCE OF INCOME AMOUNT OF INCOME
/J•�• ......:..............$ �-
�• .��.�.�.:;�-..�.: .. $ aa6�65
P,�� � �� $ �8��.�6
. . fviHR 3 i9S� . .
n TOT � ...$
�a 6✓otTz�
, SD
•Sa
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 Mortgage Deduction, do you receive any other deduction from property tax�
Yes , No �/ .
�ave you filed application for deduction in this county or any other county? Yes , No ✓.
� swear under the penalty of perjury that the above and foregoing information is true and correct.
'See False Statement Penalty Below. (On Receipt)
�' .��.�.,� Q, s:%�� �.i �.� � 7�-°z�-C� � s� 76 S<o
Filed By: Address � Phone No.
` On Behalf O/:,(Owner's Full Name) (Owner's Complete Atldress)_-. - ��