HomeMy WebLinkAboutAge_DoernerPo�m 3t3 fievisM 1970 AFFIDAVIT OF PERSON� 65 YEARS OF AGE OR MORE
PrescriMU Oy Ine State '
aoam oi ra. commiss�onns REQUESTING PROPERTY TAX DEDUCTION ^
:• `i�/l�1�
� TO BE FILED IN PERSON OH BY MAII EACH YEAR WITN THE
°r � COUNTY RUOITON WNERE OWNER'S GROVERTY IS LOCATED: � �
�` REAL PNOVEPTY - BETWEEN MARCH 1 AND M/.Y 10. INCLUSIVE ��� /
� MOBILE NOME - BETWEEN JANU/.PY 1 AND MARCH ]l^, INC^LUS^WE ! YF-
(NOT ASSESSED >S REAL PROPERTYIS/ `� _ W
(Sl.1-12-9 AND 61.1-1140.t) �
STATE OF INDIANA, %L� COUNTY, SS:
�
I, (We)_/�d�,w. /✓• ��,M1-��.�.ch� , certify that I, (We) was/were
�years of age on the �� Thaf I, (We) reside at
(STREET OR flURAL ROUeT,E) � (CITY OR TOWN) ' TOWiISIIIP�
r�-�'�- 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)
�1 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 property tax records if different from above:
�gal Description or Key Number: l Q=
sessed value of real estate or mobile home. as of
��. S�s
1, current year:
—.� —y —
u��
irriQQ/i
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
S71,000 and was derived from the following sources and in the following
amounts: _ _ _ � .a��
SOURCE OF INCOME
AMOUNT OF INCOME
' �3ba
.�n.t . ..QdNf('n�2� �Q;;; ............ s .� 1i3. 4 9
/� . ,�. . . . . . . . S _ `� �� ti -��•
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Cu �..,,�.� .�?: t�. ► s .396,�. �7
� � 'r:�_i�Jt'TOR . . .� . . . . . . . . . . . . . . .
TOTAL..S �z� �'.3 (o
9
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.
ther than a Mortgage or Contract Deduction, do you receive any other deduction from property tax?
, NO X Have you filed application for deduction in this County or.any other county7
s NO J4
I swear under penalty of perjury that the above and foregoing information is true and correct.
'See �Ise Statement Penalty Bel (On Receipt)
/ J n/ J / ..
7 7 . ,_77l = , e7�/ �4�r,l�t / �s�. , .... / i� 1%fiC.-
�Owner's Comdeie Aaaress� � .