HomeMy WebLinkAboutAge_Lytlen•. s AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, � TOWNSHIP veart
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S State Fwm 43708 (RS / 6-03)
N�
' Ptascri�ed Dy Ne Department af Lofal Govemment Finance ' ,
� File rk
Information conWined in this document is CONFIDENTIAL pursuant to IC 6-1.1-72-9.
INSTRUCTIONS: FILING DATES: SEP �� Z003
To be filed in person or by mail with the County Auditor o( the county where 1) Real pioperty: Dunng the 2 months be%re May
the property is located. 11 of the year the dedutfion is� be effecti .
-�-� 2) Mobile ho s asse nd I,�,fr� -
See reverse side for additional instruction and qualifications. 6etween J��� ��.�iC0i91Fe year
the deduc �om7r be e"(fective.
Name of appliwnt (owner or contract buye�
� � �
Is auoliwnt the sole leo eouitabie owne(1 If No, at is hisRier exact share w i ere f owned with somaone other than spouse,
� indicate vrith whom
❑Yes ❑No
If name on rewrd is difierent than Nat of applicant, indicate below
Name of conVact seiler (applicant musf have been 6uying on conUact at leas! one (7) }rear)
Address of contracl seller Is the property in question:
❑ al property ❑ Mobile home (I.C. 6-7-7-7)
`'ngd�Vict � Key number I Legal description Record number Paga number
CD � - � =G0"'c/-oZ- - :� �
Is the property used and occupied primarily for Assessed value of the property as of March 1, wrtent year (may not
hisRier residence? exceed $144,000)
5 ❑ NO
Was the applirant 65 years of age or more on December 31 of the year poes the com6ined annual adjusted gross income ot the applicant and any
prior to the curtent year? individuals sharing ovmership ezceed 525,000?
L�'S'es ❑ No ❑ Yes ❑ No
ApplicanPs
Have you filed for any other deductions? If Yes, what deductlo�s?
❑ Yes C�No
Have you filed for deductions in any oNer wunty? If Yes, what coun[y?
❑ Yes Lt3' l�o
I/We certify under penalty of pery'ury that the above and foregoing information is true and cortect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature applicant Signature of authorized representalive (by executed Power of Attomey)
,dress of appli nt Address of authorized representative