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STATE OF INDIANA,
(We)
AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE
REQUESTING PROPERTY TAX DEDUCTION
TO BE FILED IN PENSON ON BT MAI� EACN YEAN WITH THE
COUNTY AUDITON WHERE OWNEN'S FROFERTY IS LOCATED:
NEAL FROPEPTY - BETWEEN MAPCH 1 AND MI.Y 10. INCWSIVE � w ^ .
MOBILE HOME - BETWEEN JANU/HY 1 AND MAPCM ]l, INCLUSIVE ��� 1�]
(NOi ASSESSEO /5 HEAL GROPERTY) i a
(61.1-12-9 AND 61d42404)
COUNTY, SS:
certify that I, (We) was/were
65 years of age on the _ �✓ , � Thaf I, (We) reside at
(J , �
�� � Township,
(STREET OF RUflAL F^U Eh T �__ (CITY.O TOWN)
•./�l/l �1'WT County, Indiana; that i, (We) have owned the following described
eal estate
for 1(one) year or more prior to claiming this deduciion, 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 diiferent from above:
Legal Description or Key Number: ��uO1' �
�sessed value of real estate or mobile home as of March 1
"1 b
current year:
�
The total annual gross income of this affiant when combined with that�i9lGitt�
her spouse for the prior calendar year, without any deductions, did not exti�e�i
511,000 and was derived from the following. sources and in the_following
amounts:
SOURCE OFD INCQ,[v1E
AMOUNT OF INCOME
............................s a�.IS.ao
............................s 134 .9�
............................s iss�.ia
TOTAL.S 5 aa5.�
f'�
Were either you or your spouse required to tile an income tax return for ihe preceeding year? Yes �—
No If yes, a copy of such return must be submitted for county auditor's inspection.
Other than a Mortgage o ntract Deduction, do you receive any other deduction from property tax?
� NO Have you filed application for deduction in this County or any other county?
NO
I swear under penalty of perjury that the above and foregoing information is true and correct.
'See False Statement Penalty Below. (On Receipt)
.1