HomeMy WebLinkAboutAge_Emersoniy�_R•n4`.=, AFFIDAVIT OF PERSON� 65 YEARS OF AGE OR MORE� COUN71' TOWNSHIP YEA�t
` REQUESTING DEDUCTION FROM ASSESSED VALUATION
�° � Sute Fortn 43708 (R6 / 4-Oa) �
••i.
Prescr3ed by ihe Depatlment of Lowl Gwemment Finance
..orma6on contained in this document is CONFIDENTIAL pursuant to IC 6-7.1-72•9 and IC 6-1.1359.
File Mark
INSTRUCTIONS: FILING DATES:
To be filed in person or by mail with the CountyAuditor of the county where,
the property is located. L.
DJ
See reverse side (o� addifional instruction and qualifications. ,M1J\'
`Q
1) Real property: Dunng the 12 months betore May
11 of the year the deduction is to be e/fective.
2) Mobile homes assessed unde�I.C.6-1-1-7;
between January 15 and March 31 of fhe year
the deduction is to be e/fective.
Name of applicant (owner o� vact buyer) �
��Cl�, ` �
Is applipnt the sole legal or equltable owne(? If No, what is hislher exad share or interest? If owned with someone other than spouse,
indicate with whom
es � No
If name on rewrd is diHerent than that o( applicanl, Indicate below
Name of contrect seiler (applicant must have been buying on confract at leest one (7) year)
Address of conVact seller �� Is the property in ques6on:
❑ Real property ❑ Mobile home (I.C. 6-7-7-7)
Taxing district Key number / Legal description Record number Page number
� ab -� � -
Is the property used and occupied primarity for IAssessed value of the property as of March 1, current year (may not
his/her residence? exceed S 744, 000)
❑ Yes ❑ No
Was the appliwnt 65 years oF age or more on December 37 of the year poes the wmbined annual adjusted gross income of the applicant and any
prior to the curtent year7 � individuals sharing ownership exceed 525,0007
❑ Yes ❑ No O Yes O No
Applicanfs date of birth (month, day, year) Source of Income Amount of Income
spouse's age at g
the time of deaih?
TOTAL $
Have you filed (or any other dedudions? � I( Yes, what deductions?
❑ Yes ❑ No
Have you filed for deduclions in any oiher county? I( Yes, what count}? �
❑ Yes ❑ No �
I/We 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 icant Signature of au�horized representative (by executed Power ol Attomey)
dre li t Address of auihorized representative
G � E ds'oS