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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE
REQUESTING PROPERTY TAX DEDUCTION
TO BE FILED IN PEfl50N Ofl BV MAIL EAGH YEAP WITH THE
COUNTY 4UDITOP WMERE OWNER'S PROPERTY IS LOCATEO:
' REAL VNOPEPTY - BETWEEN MApCH 1 AND MI.Y 10, INCLUSIVE
MOBILE HOME - BETWEEN JANUAHY 1 ANp MApCH ]l, INCWSIVE
(NOT ASSESSED AS REAL PROPERTY) � �� /
142-9 AND 61.14140.1)
STATE OF INDIANA, UNT S: ��
t� � � �..i ,�.� -`��
I, (We) ) was/were
C° ° years of age on the � Thaf I, (We) reside at.
��� � �5 aL-r�� (/ /7� Township,
(STREET OR RURAL ROUTE) � (CITV OF 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)
❑ mobile home
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 above:
�al Description or Key Number: � � � �T � � � - —
Assessed value of real estate or mobile home as of March 1, current year. �-3 G^ -
�. - U3o
The total annual gross income of this affiant when combined with that of his or
her spouse for the prior calendar year, without any deductions, did not exceed
511,000 and was derived from the following sources and in the following
amounts:
SOURCE OF INCOME
AMOUNT OF INCOME
.............................S o?`��/ 0�0
.............................S
............................5
TOTAL. .S
Were ither you or your spouse required to file an income tax return for the pre�� �t ��
No� If yes, a copy of such return must be submitted for county auditor's A��.Qron. _
nther than a Mortgage or Contract Deduction, do you receive any other deduction from� property tax?
NO Y Have you filed application for deduction. in this County or any other county?-
�s NO �� � - , °
I swear under penalty of perjury that the above and foregoing information is true and correct. � `?
'See False Statement Penalty Below. (On Receipt)
, �.-� ��,,.P.��� � 330 7'l. /`�a-� ��