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F""'3�R"'s""�' AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE
a�rno�a M v�.e
BaarO oi Ta� w�,�����«. REQUESTING PROPERTY TAX DEDUCTION
� TO BE FILED IN PERSON OR BY MAIL EACH YEAR WITH THE
COUNTV 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
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STATE OF
(NOT ASSESSED AS REAL PROPERTI�
(6-1.1-12•� AND 61.1-1240.1) O �� ��
age orythe�
�SThat I, (We) reside at
R� �. � oZ /,3 v,¢.t�ar�.-x.� _� • �.� �� b� Township,
V et or Rural Route) (City or Town)
i--✓ ��/ County, Indiana; that I, (We) have owned the following described
l� real estate for 1(one) year or more prior to claiming this deduction, and that I, (We) now reside in
t7 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
Legal Description or Key Number:
value of real estate or mobile home as of March f, 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:
SOURCE OF INCOME
AMOUNT OF INCOME
�--�'�(��,> . . . . . . . . . . . . . . . . . . $ 5/.5 �: /�'
$
. . . .� � ���' . $ I
MAR i98G
i
Were eith ou or your spouse require��f�. return for the preceeding year?
. If SU Rr t must be submitted for count auditor'sl
Yes� No yes, a copy �it} �€A e y
inspection.
Other than a Mortgag�eduction, do you receive any other deduction from property tax?
Yes No
�Have you filed applicafion 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)
� �� ,� . � Y'if�..��,-,�� �
Filed B Address c� Phone No.
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