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FOtm 323 Pe:aCtl 1981
Prexribetl Cy �he 50�e
9oa�a ot ra. wnmis:ioners
��l
STATE OF INDIANA,
AFFIDAVIT OF PERSONO, 65�AR5 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 PROPERTV IS LOCATED:
REAL PROPERTY BETWEEN • BETWEEN MARCH 1 AND MAY 10, INCLUSIVE
MOBILE HOME • BETWEEN JANUARY 1 AND MARCH 37, INCLUSIVE
(NOT ASSESSED AS REAL PROPERT`�
(61.1-12-9 AND 6-1.1•12•10.1)
a,%(�1 COUNTY, SS:
I, (We) 1 I Q ��.[JQ nd n--�� , certify that I, (We) was/were
��years of age on the� � . That I, (We) reside at
� � � ,g• -S'�1�'Y�,pni �lAdc�,c �x�\ Township,
(Street or Rurai Route) (Crty or Town)
County, 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�'�beJg�made by surviving unremarried spouse:
Spouse's age-at`the'time of death: .
Name of property tax recortl"s9f differeni�from above:
Legal Description or Keyy,�NLU�nb�er:�• -- `C�1r,n�CkrcY�
AUDITOR �� V
Assessed 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 $10,000 and was
derived from the following sources and in the following amounts:
SOURCEOFINCOME
AMOUNT OF INCOME
�0,�,�� .....................$ 3s87�b3
L3p�n . . . . . . . . : . . . . . . . . . . . . . $ /.s �. �/.�
' � . . . . . . . . . . . . . . . . . . . . . $ �j'/3. �D
(�, ' TOTAL ...$
Were eit r 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 Mortgag 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 .
ti`� Swear under the penalty of perjury that the above and foregoing information is true and correct.
. `See False Statement Penalty Below. (On Receipt)
a
ed By:
On Behalf Of: (Owner's FuII�Name) (Owner's Complete Address)
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