HomeMy WebLinkAboutAge_Harkness�� �s��' AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE
eoa° °"°` `°'"m""°""� 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 MARCN 31, INCIUSIVE
(NOT ASSESSED AS REAL PROPERTI� �
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STATE OF INDIANA,
(6-1.1-12-9 AND 61.1-12-10.1)
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I, (We) ��LO�-Y/'�x- �/. �1f'�yzQ.Q� , certify that I, (We) was/were
�years of age on t That I, (We) reside at
�.J(J �UXSZ ,x!��lJ«( Township,
(Street or Rural Route) (City or Town)
County, Indiana; that I, (We) have owned the following described
�al 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:
0
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 diffei
Legal Description or Key Number:.
value of real estate or mobile home as of March 1, current year:
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 th�following sources and in the following amounts:
SOURCE OFI
AMOUNTOFINCOME
-�a�. � !�/O%S.•%�
, $
�f; ,. � _�98s . . . . . . . . . . . . . . . . $ a o y i�
TOTAL ...$
Were eit 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
inspecUOn. �
OeSer than a Mo�rtgag eduction, do you receive any other deduction from property tax?
,.
Have you filed application for deduction in this county or any other county? Yes , No �
�swear under the penalty of perjury fhat the above and foregoing information is true and correct.
'See False Statement Penalty Below. (On Receipt)
. ,
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Filed By: iWdress
On�t: (Owner's Full NameJ
Address)
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No. E�