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'°« �' flevise°'�^ AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE ��
fie5cn0eJ Oy t�e Statt
ew�a oi ra. commmsio�er: RE�UESTING PROPERTY TAX DEDUCTION
TO BE FILED IN PENSON ON BY MAIL E4CH YEAfl WITH TNE
COUNTY AUOITOP WHENE OWNER'S PPOVERTY IS LOCATED: , � �
NERL PHOPENTY - BETWEEN MANCH 1 AND MAY 10, INCLUSIVE
MOBILE NOME - BETWEEN JANU/NY 1 AND MARCM J1, INCLUSIVE
(NOT /.SSESSED AS REAL PROPERTY) '/_'�1 y��/
� 16-1.1-12-9. AND 61442404) � I V`� I �,J .
STATE OF INDIANA, ��1r COUNTY, SS:
� . .
I, (We) � rvr , certify that I, (We) was/were
�years of age on the �—. Thaf I, (We) reside at
�� Q� � ,� � �—�-�C�'' � Townshi
�STREET OF RURAL flOUTE) (CIiY OR Tp� p�
�� 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)
❑ 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 properry tax records if different from above:
i_egal Description or Key Number. / °�
P-� .,b���y ��r� i�r-�-q. . g�;s - =�
,sessed value of real estate or mobile home as of arch current year:
/S7� -.3500
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 irom the following sources and in the following
amounts:
SOURCE OF INCOME
AMOUNT OF INCOME
���� ol � .............................5
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Were eit er 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 Mortga�r Contract Deduciion, do you receive any other deduction from property tax?
s NO _L Have you filed application for deduction in this County or any other county?
s NO l/ - _ %
1 swear under penalty of perjury that the above and foregoing information is true and-correct. .
'See False Statement Penalty Below. (On Receipt) - �
e,
,
�Owner's Complete AOOress�