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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE
RE�UESTING PROPERTY TAX DEDUCTION
TO BE FILED IN PERSON OR BY MAIL EACH VEAR WITH THE
�� COUNTY AUDITOR WHERE OWNER'S PROPERTY IS LOCATED:
REAL PROPERTY BETWEEN - BETWEEN MARCH 1 AND MAY 10, INCLUSIVE
MOBILE FiOME - BETWEEN JANUARY 1 AND MARCH 31, INCLUSIVE � /�
(NOT ASSESSED AS REAL PROPERTY) �
(61,1-12-9 AND 61.1-12-10.1)
STATE OF INDIANA, �� COUNTY, SS:
I, (We) , certify that I, (We) was/were
.r�years of age on . That I, (We) reside at
� r�.3 Iv /�L�,�(1P� � , � Township,
(SVeet or Rural Route) (City or Town) , _.
County, Indiana; that I, (We) have owned the following described
C�+' real estate for 1(one) year or more prior to claiming this deduction, and that I, (We) now reside in
❑ mobile home
the remises-for{�wh�ich this deduction is claimed:
Sur pving Spf ou e: rlf-applicati ��is being made by surviving unremarri�e s�e�
Spouse's age at the time of death: . C p �(p — O�'-1� -��
UG i . I��}j�i
Name of property tax records if different from above: I�i ��. I �
Legal Description'Co�(Key�N�ber:
�
�4ssessed value of real estate or mobile home as of March 1, current year: _ _ _
. . .
Were ei 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. ,_ .�
Other than a Mortga Deduction, do you receive any other deduction from property tax?
Yes , No .
�iave you filed application for deduction in this county or any other county? Yes , No
I swear under the penalty of perjury that the above and foregoing information is true and correct.
"See False Statement Penalty Below. (On Receipt) �
F d � P,ddress Phone No.
On Behalf Oi: (Owner's Full Name) (Owner's Complele Address)