HomeMy WebLinkAboutAge_ConleyFor.� 3Z3 Rerisetl t 98t
Presu��etl by Vie Sta�e
Boara ot iaa Commissiantts
'•
STATE OF INDIANA,
AFFIDAVIT OF PERSON, 65"YE"ARSO�AGE OR MORE
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 PROPERTY BETWEEN - BETWEEN MARCH 1 AND MAY 10, INCLUSIVE
MOBILE HOME - BETWEEN JANUARY 7 AND MARCH 31, INCI.USIVE
(NOT ASSESSED AS REAL PROPERTV)
1•12-9 AND &1.1•12•10.1)
�, �e� c o � i. � �
�years of age on the �
. That i, (We) reside at
Township,
./.�-�_� County, Indiana; that I, (We) have owned the following described
�l 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 from
Legal Description or Key Number:
0
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 following sources and in the following amounts:
SOURCE OF INCOME
Q. ��
�� $
AMOUNT OF INCOME
� . . . . �iF� .�. � .�5.a�. . . . . . . $ ��s� n o
�,��.�. � . . . . . . . $ � � � � o �
i�x�:=.0 �6` ii' .: s. . . .
AUDIFORTOTAL . . . $ �1 lc �Z � , 0 0
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?
Yes , No
�ave 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 irue and correct.
'See False Statement Penalty Below. (On Receipt)
/'� sQ, 7i% ��� �� '�` 5` /�� •1l(� / JiLc�.�,��, �
Filed By: Address Phone No.
/l
O�f: (Owner's Full Namf) . �'1_ _ y� (Owner's Com I�ete Address)