HomeMy WebLinkAboutAge_Brines��
P�essiEeE by Ne Sas
Boara at iaa Commrssianers
�•i
STATE OF INC
AFFIDAVIT OF PERSON, 65 YEARS OF A� O��
REQUESTING PROPERTY TAX DEDUCTION
TO BE FILED IN PERSON OR BY MAIL EACH YEAR WITH TFiE
COUNTY AUDITOR WHERE OWNER'S PROPERTY IS LOCATED:
REAL PROPERTV BETWEEN - BETWEEN MARCH 1 AND MAY 10, INCLUSIVE
MOBILE HOME - BETWEEN JANUARY i AND MARCH 31, INCLUSIVE
(NOT ASSESSED AS REAL PROPERTn
1�/Ie.*�7�71/1
r•-
. � .�- � � •.
1-12•9 AND 61.1-12•10.1)
u
, SS:
certify that I, (We) was/were
19�. That I, (We) reside at
.
��.,r�.co Township,
(Street or Ru� iCity or Town)
, ` 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) 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
Legal Description or Key Number: s ���'
�
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 $10,000 and was
derived from the foliowing sources ancjl�4 tij� fQllow� a o� nts:
,�; 1l, �.�
SOURCEOFINCOME AMOUNTOFINCOME
P,hAR 1 J
S7GS�� ... ..... ....$ S��S
�S �: �:��:�..
H_�DITC� $ '
TOTAL ...$
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 Mortgag Deduction, do you receive any other deduction from property tax?
�s No�. '
ve 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)
Filed By:
.�Gri�t/�/�i ? �� .%£.VL(m-GO�
,� Z � ,J�Q.��-
Address Phone No.
��_ _ �
+