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STATE OF (IN1DI�ANA,
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AFFIDAVIT OF PERSON, 65 YEARS OF AGE.OR MORE
REQUESTING PROPERTY TAX DEDUCTION
TO BE FILED IN VERSON OR BY MRIL EACH YEAH WITH THE
COUNiY AUOITOP WHENE OWNEH'S VROiERTY IS LOLATED:
FEAL PHOPERTY - BETWEEN MARCH 1 AND MRY 10, INCLUSIVE
MOBILE NOME - BETWEEN JANUAflY 1 RND MANCH 71, INCLUSIVE
(NOi ASSESSEO AS HEAL FHOVENTY� `
(E1.14Z-9 RNO 61.1-1240.11
COUNTY. SS:
/✓ �
�./ / /
certify that I, (We) was/were
—f2�years of age on the ��� ° c:haf I, (We) reside at
� ` • Township,
(STflEET OR RURAL � )(GITY OR TOWN)
��-.�-�/ nty, Indiana; that I, (We) have owned the following described
I� real estate
❑ mobile home
for 1(one) year or more prior to claiming this deduction, and That I, (We)
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: _
�ial Description or Key Number. �� .C� ��
Assessed value of real estate or mobile home as of March
.
current year: ~ — =
/�t ISoo -�37a
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
511.000 and was derived from the following sources and in the Tollowing
. amounts:
SOURCE OF INCOME AMOUNT OF INCOME
�-��0 �..�!� � a . . . . . . . . . . . . . . . . . . . . . . . . . . . S �"� i O . �'l'
,�
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AL..S
�i'IH� 1 1'ae�
Were either you or your spouse required to file an inc e tax return for the preceeding year? Yes�
No If yes, a copy of such�t� d for county auditor's inspection.
AUDITOR
�' ` ^�her than a Mortga or Contract Deduction, do receive any other deduction from property tax?
�.:� ;� NO � Have you-filed application for deduction in this County or any other counry?
�ies NO �. `
I swear under penalty of perjury that the��above and` foregoing information is true and correct. � ;-
_---�See False Statement Penalty Below. (On Receipt) � i