HomeMy WebLinkAboutAge_Potts e "� APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
b ...itgaii Prescribed by he Departure o)f Local Government Finance
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Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9. MAY 6
Address of contract seller(number and street,city,state,and ZIP code) Is the property in question:
❑ Real property ❑ Mobile home(IC 6-1-1-7)
Ta ing district �nKey number/Legal description Record number Page number
• /61 A -dot-f /a 'o-�.‘As_6/y
s the property used and upied primarily for Assessed value of the property as of March 1,current year(may not exceed$182.430
his/her residence? for Over 65 deduction,or$760,000 for the Over 65 Circuit Breaker Credit)
,Yes I I No
Was the applicant 65 years of age or more on December 31 of the year
Have you filed for any other deductions? If Yes,what deductions?
❑ Yes ❑ No
Have you filed for deductions in any other county? If Yes,what county?
❑ Yes / 4`( No
I)We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 .
Signature of applicant
.741 e ,{/,` ,,j Address of applicant (number and street,city.state,and ZIP code)
I //44 �-7n �H i 76V, X
Sign of authorized representative Address of authorized representative (number and street,city,state,and ZIP code)
Fam 3L1 flevisM I920
Prescrice0 Oy me Siate
BaarO ol ia. Camnissianers
� �
STATE
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AFFIDAVIT OF PE�N�, � EAR OF AGE OR MORE
REQUESTING PROPERTY TAX DEDUCTION
TO BE FILED IN VERSON OR BY MAIL EACH YEAR WITM TNE
COUNTY AUDITOR WHERE OWNEP'S GROFERTY IS LOCATED:
REAI PROPEFTY � BETWEEN NAPCH 1 AND MAY 10. INCLlI51VE
MOBILE HOME - BETWEEN JANU>flY 1 AND MAFCN 71, INCLUSIVE
(NOT RSSESSEO /5 HEAL PPOPEPTY)
(61.141-9 AND F1.14240.t�
COUNTY, SS:
i
I, (We) , certify that I, (We) was/were
�years of age on the �- That I, (We) reside at
- Township,
(5 �EET O�R(�9UflAL ROUTE) �GTY OR WN) . -
�L�.1'.,?�6""'� County, Indiana; that I, (We) have owned the following described
�feal estate
for 1(one) year or more prior to claiming this deduction, and That I, (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:
�gal Description or Key Number: �'�ti t�6G V d. b �
G( �/ �
Assessed value of real estate or mobile home as of March 1, current year:
�
1��: �.
� o�. �1 S 0-C
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 tollowing sources and in the following.
amounts:
SOURCE OF INCOME AMOUNT OF INCOME
�.��G,.� ............................. s 3�1g.,' �.
� ,� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S l 3 �!s', u q
�. .............................5 ac�aa.n�
TOTAL..S �DOO ,O'0
Were either you or your spouse required to tile an income tax retum for th��e din���!lres
No If yes, a copy of such retum must be submitted for counry.. u_ �o%�
^ther than a Mortgage or ConVact Deduction, do you receive any other du�tion�gy�qJn property tax?
�s NO Have you filed application for deduction in thi��b�nty or any other county?
Yes NO
�i�CC� �8' Yt� s
I swear under penalty of perjury that the above and foregoing information is t���cdfrect.
'See False ,6tatement Pena)i,y Below. (On Receipt) �