HomeMy WebLinkAboutAge_Modafari,°� �,rt.• � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
iP REQUESTING DEDUCTION FROM ASSESSED VALUATION
� ,��� � State Form 43708 (R6 / <-Oa) �
Presuibed by the Department ol Local Govemment Finance
Information wntained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12•9 and IC 6-1.1-359.
COUNTY TOWNSHIP YEAR
File Mark
INSTRUCTIONS: FILING DATES:
To 6e filed in person or by mail with the County Auditor o( the county where 1) Real property: During the 12 months 6elore May
the propeRy is located. 11 pf (h th d d t' ' t b ff '
See reverse side fo� additional instruction and qualifications.
or wntract
Is applirant the sole �gjl or equitable ovme� �Ii No, what is his/her exa/j/�hare or
name on rewrd is tliHerent t
3me of contract seller (appli<
idress of contract seller
Yes ❑ No �
Ihat of appliwnt, indicate t
musf have been buYinp on
and occupied primarily (or
the applicant 65 years of age or more on
to the current year7
e year e e uc ion �s o e e ect�ve.
2) Mobile homes assessed under 1.C.6-1-1-7;
behveen nuary� S�nd Me h 3 o e year
fhe deducl%i�is t�o 6e�e Ject vre. .
JL �J
MAR 2 2007
spouse,
GIBSON CUUNTY
Is the praperty in question:
-1 3- D- a00 - 600.0.�-00�( � Real property ❑ Mobile home (I.C. 6-1•1-�
Key number / l.egal description Record number Page number
_ �Sa_�
Asseued value of the property as of March 1, cunent year (may not
exceed $144,OOOJ
es No
:ember 3 Ihe year poes Ne combined annual adjusted gross income of the applicant and any
individuats sharing ovmership exceed 525,0001
�IicanCs date of birth (monfh, day, year)
ed by a surviving, unmarried spouse, what was
Ume of deaNY
you filed for any other deduciionsl
you
any other
d'Ves ❑ No
he spouse's age at
If Yes,
❑ Yes ❑ No
If Yes,
❑ Yes ❑ No
$
❑ Yes O No �
I/We certify under penalty of pery'ury 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 apnplicant Signature of authorized representative (by executed Power olAttomey)
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