HomeMy WebLinkAboutAge_Kelle� COUNTY TOWNSHIP YEAR
AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
- REQUESTING DEDUCTION FROM'ASSESSED VALUATION
S � State Fortn 43708 (R7 / 5-06)
�� Presmbed by tlre DeD��ent af Loral Govemmeni Finance
eM
Infortnation coniained in Ihis dowment is CONFIDENTIAL oursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
INSTRUCTIONS: FILING DATES.AU�j � p ZO H /
To be (led in person or by mail with the County Auditor of the county where 1) Real properry: Dunngihe 1� months 6efore June
the property is located. 11 of the y e dedu ho is to be eNective.
2J Mo6ile ho er I.C.6-1-7-7;
See reverse sfde for additional instruction and qual�cations. betw¢� �� �`�d�� �7 of the year
fhe de�ct�on is o 6e eflec �ve.
r,.=
FSi
applirant the sole le�l or
❑Yes ❑No
name on record is d"rfiere�t Man that of appliprt
seller (applicanf must have
the apd�t 65 years oT age a more on
to the wrrent year?
No, what is hisfier exact share a
on conhact at least one (1) year)
r�: � � �f�0-000�
If owned vrith someone oNer than spouse,
irMicate with wFwm
Is the property in question:
�Real property ❑ Mobile home (I.C. 67-7-�
� Recad number Page number
� . Assessed value ot the property as of March 1, current year (may rrot
- exceed $744,000)
QYes ❑No
mber-37 of the year Dces the combined annual adjusted gmss income of the applinnt and any
, individuals sharing ownership exceed $25,000?
DYes ❑No �Yes ❑No
Source of Income Amount of Income
� b��surviving, unmartied spouse, whai was ttie spouse's age at
6me of death?
�e you filed for arry olher deductions?
❑Yes ❑No
�e you filed for deductions in any other county?
what
Yes, what county?
$
$
TOTAL S
i:.
�Yes ❑No I
I/We certify under penaliy of perjury that the above and toregoing infcv*n�+��n is We and correct and thal the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
gnature of applicant Signature of authorized represeniawe (by executed Power ofAttomey)
�
ress of aodicant Address of aufhorized representative
S . /�Sp