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Ferm lfi6 Revieed 19]9
- i'r.TCriMd by �he Stwte
}l.•�rd of Tex l'w�mmie�ionen
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A1�FIUAVIT FOR I3LIND OIt llISABLEll PP1tSON'$���'UC�I(?�
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'f0 f3E FILED IN PEItSON OR BY b1.UL EACH YPAR K'17'F{ TIiHr�r�` � J �
COUN'TY AUUITOIi 13E'I'WliGN MANCtI 1 AND AtAY 10, INCLU51��6 �r
FILIIv`G INPORIHAI'lON ON 13ACK ..`, �,�U��;(�a
STA'I'E OP Ih'pl_1\TA ..........��.._._. COUNTY, SS: ,
�..N!-cDl��.. ...C�...� .............................._... being duly sworn, on oath says that he m-she
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Slrr.cc ' ' ) City ' 1 County .
Indi�ina; that � he or s1 e is a di 1Lled�persongas def3ned in� the I�ndia� a�Code G-3-3-6�( )(H) :
u��•uing rc:il estate which ie used and occupied pri��cipally for his or her residence, and that his or her tazable gross
iucume (esclusive of any income not taxed uuder the fede!•a! i!icome lax laws) is �iot in�excess of �for the
immediately preceding calendar ye1r.
'1'hat this atfidavit is made for the purpose of having two Lhousand ($2,00 ) dollars deducted from the assess-
���alsuation of the foll�ow(�i,ng described taxaUle property for Dthe /y�ear 1�iFS.�o w;t: ........ __..... ........._..
. .0 '.sa..�..-z..�.. �.�4�(i.. . . r �...C�.. ! �-/��3. s:9 .. .�-.�. .. '`'"
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ueing the applicant's principal residence pursuant to IC G-1.1-12-ll and 6-1.1-12-12.
Subscribed and sworn to b re me this .......�.1?-�..
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. Applicant
d1y of � O.k--�.- - � 19..��
FOK AUDITOR'S USE
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Total Assessed V:�lue of Taxable Property for year 12..5..t� s��. �a��
....... .. ... ........ .. ...... ....:....................... TownshiR Real Estate _ . _ . . .. .. .f?.�
Corporation
Assessed in Lhe name of .,.�...1�- `
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Aniount ot Taxable Yroperty Deducted $
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. A`et Value of Taxable Property $..._......
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