HomeMy WebLinkAboutAge_Douganeex�ibeabyNeSaY AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE
B°"° °; "' `°"""'�'°""� 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 1 AND MARCH 31, INCLUSIVE
(NOT ASSESSED AS REAL PROPERTI�
(67.1-12•9 AND 6-1.1-12-10.1)
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STATE OF INDIANA, j�..Q1�i� COUNTY, SS:
I, (We) a� , certify that I, (We) was/were
�e � years of age on the� That I, (We) reside at
i
R �� G � . , �('A� , � '�� Township,
(Street or�ural Route (City or Town)
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 from above:
Legal Description or Key Number:
.�,ssessed value of real estate or mobile home as of March 1, current year:
1 u'fes . � I
l�
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 $10,000 and was
derived from the following sources and in the following amounts:
SOURCEOFINCOME
�O . � - .....................$
�%r.�C - .....................$
...,J...
L�
$
$
AMOUNT OF INCOME
Were eit�r you or your spouse required to�,fL�� in¢"c� tax retum for the preceeding year?
Yes , No . If yes, a copy o{ such re m ust be submitted for county auditor's -
inspection.
�•�•
AUDITOR
Other than a Mortga� Deduction, do you receive any er deduction from property tax? ,
�"es 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 true and correct.
`See False Statement Penalty Below. (On Receipt) `
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