HomeMy WebLinkAboutAge_Buckn•n 1 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�`' � State Fwm 43708 (RS I6-03)
. . Ptaxri6etl by Me Department oF Local Govemment Finance
Informatlon contained in Nis document is CONFIDENTIAL pursuant to IC 61.1-72-9.
�rRUCnoNS:
To 6e filed in person or by mail with the County Auditor o/ the crounty where
the property is Ixated.
See reverse side for additional instruction and qualifications.
COUNTY TOWNSHIP YEAR
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��ej F'ile Mark'�
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FILINGDATES: DEC 'I ,rj 2 Q3
1) Real property: Dunng the 12 mont�sbefore May
11 of the yea�lhe deduction isdo be effective.
2) Mobile ho�s asse, ssed�unde�jl.C.6-1� iJ�
between January�l5 e� March �i�olUne�year
the deduction is to be eNective.
Name of applicant (owner or tonhact buye� -
V`
Is applicant the e legal or equitabie ownerl If No, what is hisRier exact share or interesi? It owned with someone other Nan spouse,
indicate with whom
�Yes ❑ No
If name on rewrd is diRerent than Nat of applicant, indicate below
Name of conVad seller (applicant must have been buying on contracf at least one (7) yearJ
Address o( conVact seller Is the property in questlon:
Real property ❑ Mobile home (I.C. 6-7-7-n
Taxing distnct �/ Key number I Legal description Record number Page number
Q�� �L/� • W�-6.�� �� �
e property used and occupi d pnmarily for - P,ssessed value of Ne pmperty as of March 1, curtent year (may not
ner residence? ezceed $144,000)
❑ Yes ❑ No
Was the applicant 65 years of age or more on Oecember 31 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the current year? individuals sharing ownership exceed 525,000?
❑ Yes ❑ No ❑ Yes ❑ No
ApplicanPs date of biAh (monM, day, year) .
Have you filed for any other deductions? If Yes, what deducUons?
❑Yes ONo
Hava you filed for deduaions in any other county? If Yes, what wun[y�
O Yes ❑ No
IIVJe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _ `•
.
Signature of pliwnt �� Signature ot autho�zed representative (by executed Power o(Attomey)
ow :
Add s of appl Address of authorized representative
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