HomeMy WebLinkAboutAge_AlbrightForm323Revise01981 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE �b Q
Pres'iiDea b��e 50e
BoarG al Tax �mm��,�a�e« 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 PROPERTV BETWEEN - BETWEEN MARCH 1 AND MAY 10, INCLUSIVE U i
MOBILE HOME • BETWEEN JANUARY 1 AND MARCH 31, INCLUSIVE '�
(NOT ASSESSED AS REAL PROPERTI� �
i .
� (6•1.1-12-9 AND 61.1-12-10.1)
STATE OF INDIANA, /� COUNTY, SS:
�
certify that I, (We) was/were
�_years of age on the � . That I, (We) reside at
� �% � � , 7'�,r� �oz�rn- , Township,
(Street or Rural'Route) (City or Town)
/-�� County, Indiana; that I, (We) have owned the following described
�
�J real estate for 1(one) year or more prior to claiming this deductibn, 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: �i�.�-c-e� �iQ�.�r. %� �.t
:. �;�sessed �ialue of real estate or mobile home as of March 1, current year:
The total annual adjusted gross income of this affiant when �ombined 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
�j� . - -
�. �. $
�.�.....
o.00
'� � A2'T6'1�8.�. . . . . . . . . . . . $ �io
�...................$
�"� �'�T:.b�t��^ $ � o o. o 0
AUDITOR `�TAL ...
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?
'es No x
� a�ie you filed application for deduction in this county or any other county? Yes , No 4
��=:
I swear under the penalty of perjury that the above and foregoing information is true and correct.
'See False Statement Penalty Below. (On Receipt)
��� ¢�'��� �,/./� �...<�- ��,(n ��.-�, ,� �' �'� � �
Fie y: —� Address _ _P+oneNO.
� 1
On Behalt OC (Owner S Full Name) / (Owner's Complete Adtlress) � -`'
, `-