HomeMy WebLinkAboutAge_Tolbert (3)Fwm 323 Ravisetl t98t
PrescribeC by Ne Stl�
BoaeE ol ia. Comm¢siwers
��
STATE OF INDIANA,
�
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 REAI PROPERTI�
(&1.1-12-9 AND &1.1-12-10.1)
:'�I� �� d�
UNTY, SS:
that I, (We) was/were
��years of age on the�� �—� . That I, (We) reside at
� '� / %�a-X `�-73 %�,(t�ia, , (d/�_ �u.r�. Township,
(Str et�ROUte) Q (City or Town) �_
� County, 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: �� %�7 • 7 - �'1 ' � ' � o � � 9 R�
�,i„ a./ -, _ - - ��'i �
_wssessed value of real estate or mobile home as of March 1, current year: -
. / _ _ / �1 .. iw [L _
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
�� i �� '�;�'i � � , .
r9�/u.�. .MAR�15.1ggc . . . . . . . . $
�, ci.
$
�/ /b'.o
.26 ��.o
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?
Y�es No �
�!ave you filed application for deduction in this county or any other county? Yes , No �
0
I swear under the penalty of perjury that the above and foregoing information is true and correct.
'See False Statement Penalty Below. (On Receipt) `
?�_��„ .� `�-. � / P-o-x �-i3 %4�,!<-� -
Filed By: Address Phone No.
/
(Owner's Comolete'{ ddress)