Age_Sullivan (3)oi�-o�oi�
Fo«YJ ReviSM 1900 AFFIDAVIT OF PERSON� 65 YEARS OF AGE OR MORE
aresmx� ey me 5ta;e
eoam m ta. co��:i�ers REQUESTING PROPERTY TAX DEDUCTION
TO BE FILEO IN GENSON ON BY MAIL EACH YEAH WITH THE
COUNTY AUDITOR WHEHE OWNEP'S PPOPENTY IS IOCATEO:
� RERL PROPERTY - BEiWEEN M4RCH 1 AND MAY 10. INLLUSIVE
MOBILE HOME - BETWEEN JANU/.NY 1 AND MAqCN ]l. INCLUSIVE
-� / � /^1 I�(NOT ASSESSED <5 REAL PflOPERTY� - 1 nW!
1 ^/ _, yy•, (�.l-�9^D61'-1]-10.1) .. `.�.�KA�� 1 1�W`^+�+�i'� /y�Y(/�.+
� I V \� a
STATE
I�
�eal estate
❑ mobile home
�
Thaf
(We) was/were
(We) reside at
Township,
that I, (We) have owned the following described
for 1(one) year or more prior to claiming this deduction, and That I, (We)
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 oi death:
" Name on properry tax records if differe
Legal Description or Key Number. \� /_.� �_�
�sessed value of real estate or mobile home as of March
� -�o . �a�
current year: � O O Q ^��( �/
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
OF
' ....................�........5
__
.............................5
.liti ��. t(.c!„ . . . . . . . . . . S
� �� ��
_ TOTAL..S
AMOUNT OF INCOME
,� S
Were either u or your spouse requirec��Eqt�tii�'tir�m tax return for the preceeding year? Yes
No If yes, a copy of such return m. e submitted for county auditor's inspection.
Other than a Mortgage Con t Deduction, do you receive any other deduction from property � tax?
, NO ave you filed application for deduction in this County or any other county?
NO
I swear under penalty oi perjury that the above and foregoing information is true and correct.
'See False Statement Penalty Below. (On Receipt). � �}
\� A /��fL• X!�(ivCM/� / � %�Y ' V���'.o "—'^'�_ __/ /���� LY/r
� (�'ner'S Full Name) (Owners ComDlete Otlress)
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