Age_ChristmasFa�m 3Z3 fleviseE 198U
Prescrinea ey me SUte
BmrG of ia� tommissioners
�
STATE O INDIANA,
�, �We�
� �years
.
(STREET . P/�L UTE)
real estate
❑ mobile home
AFFIDAVIT OF PERSON, 65 YEAR�A�EOOR MORE
RE�UESTING PROPERTY TAX DEDUCTION
TO BE FILED IN PENSON OR BY MAIL EACM YEAF WITN THE
COUNTY AUOITOR WHERE OWNER'S PROPENTY IS LOCATED:
FEAL PFOPEFTY - BETWEEN MARCH 1 AND MAV 10, INCLUSIVE
MOBILE HOME � BEiWEEN JANUARY t AND MAFCM 31, INCLUSIVE
� (NOT ASSESSEO AS PERL PROPENTY)
AND 61.142-t0.p
��i��
�
_. Thaf I, (We) reside at
Township,
Indiana; that I, (We) have owned the following'described
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,�: ��
��al Description or Key Number: �, �
Assessed value of real esta[e or mobile home as of March 1, current year: �� � 3�
. � �
r�uv�wn - �=
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.
�tier than a Mortga e C t Deduction, do you receive any other deduciion from property tax?
� NO Have you filed application for deduction in this County or any other county?
- r�s NO ,
I swear under penalty of perjury that the above and foregoing information is true and correct.
'See False Statement Penaliy Below. (On Receipt)
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