HomeMy WebLinkAboutAge_Sims__ �.n! AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
" • REQUESTING DEDUCTION FROM ASSESSED VALUATION
y��� ! State Form 43708 (R4 / 10-01)
Prescnbed by Ne Department of Local Govemmenl Fi n ��
�mafion wntained in this dowment is CONFIDENTIAL Dur ant tc�C 1.1-1 =� �. �
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INSTRUCTIONS: 1
To be filed in person or 6y mail with fhe CountyAuditor of theFc��nt}}�e�0�
the property is located.
See reverse side for additional instruction and quaf � af�pry 'i-`-��, in
OU TY hUU17G;{;
COUNTY TOWNSHIP YEAR
File Mark
FILING DATES:
1) Real pioperty: During the 12 montYs before May
11 0/ the year the deduction is to 6e eHecfive.
2) Mobile homes assessed unde� 1.C.6-1-1-7;
between January 15 and March 31 0/ fhe year
the deducfion is to be e(fective.
Name of applicant owner or wnfrecf buyer�
r ���� �
/ I-/ J
Is applicant �he sole legal or equita le ovmer? If o, what is ' exact share or inlerest? If owned with someone olher than spouse,
.�� � indicate with whom
Nn'es ❑ No
t( name on record is diflerent �han that of applirant, indicate below
Name of contrad se0er (applicant must have been buying on contract af least one (1J year)
Address o( contracl seller Is the property in question:
❑ Real pmperty ❑ Mobile home (I.C. 6-14-7)
Ta�dng district Key number / Legal desaiptlon Record number Page number
��n�. I �OOa=0.0 G./_O—D o
Is the property used and ocwp d primarily (or Assessed value of the property as ot March 1, current year (may nof
hisRier residence? exceed 569,000)
Yes ❑ No
Was the applipnt 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the artent year? �� individuals sharing ownership exceed 525,000?
V✓Yes ❑ No ❑ Yes ❑ No
ApplicanCS date of birth (month, day, year)
L!1'1'es ❑ No ��� '
Have you filed for deduclions in any other county? If Yes, whai wunty?
❑Yes �7No
I/We certify under penalty of perjury thal the above and foregoing information is true and correcf and that the applicant was a resi-
dent of Indiana and owner of lhe aforementioned property on March 1, 20 _
SignaNre oi pplicant Signature of authorized representative (by executed Power o/AttomeyJ
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V�
ess ppii Address of aulhorized representative
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