HomeMy WebLinkAboutAge_Lee (4)FOm1323 flP+s¢d 1981
Rescrioea Cy tne Sta:e
Bw�E of Ta� tar.unasioners
�
AFFIDAVIT OF PE�SON,`65 YEARS OF AGE OR MORE
REQUESTING PROPERTY TAX DEDUCTION
TO BE FILED IN PERSON OR BV MAIL EACH YEAR WITH THE
COUNTY AUDITOR WHERE OWNER'S PROPERTY IS LOCATED:
REAL PROPERTV BETWEEN • BETWEEN MARCH 1 AND MAY 10, INCLUSIVE
MOBILE HOME - BETWEEN JANUARY 1 AND MARCH 31, INCLUSIVE
(NOT ASSESSED AS REAL PROPERTI�
(61.1•12-9 AND 61.1-12•10.1)
STATE OF INDIANA, fi7�,G�s-�x- COUNTY, SS:
I, (We) � T�- , certify that I, (We) was/were
1¢./_years of age on the� . That I, (We) reside at
�02 / �. �J,�e.C,�. , �itic�1"vr- , Township,
(Street or Rural Route) (City or Town)
_� l�tiw,�. County, Indiana; that I, (We) have owned the following described
�I 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:
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 $10,000 and was
derived from the foliowing sources and in the following amounts:
SOURCE OF INCOME AMOUNT OF INCOME
.�a..�.�. (,�.�� � T � � �
.. .. . ... .. .. .$ —
. .....................$ 5��oa
���- ,e ,e � APR 1 1987 $�`8 9 7, a 7:
� ��� ��� $� s�7/ �t4
.�; �,�'`��-�+S�A n. . .
,.:'n�Tn..
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 eduction, do you receive any other deduction from property tax?
'es No .
'3ve you filed application for deduction in this county or any other county? Yes � , No � .
I
I swear under the penalty of perjury that the above and foregoing information is true and correct.
"See False Statement Penalty Below. (On Receipt)
i��� �.�-e-- 3.z i 7'i . 7� ��-.�� ,�.
Filed� y.� Address ��`e Phone No.
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