HomeMy WebLinkAboutAge_Hartley_ �_ �.. = AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNrr TOWNSHIP veaR
° REQUESTING DEDUCTION FROM ASSESSED VALUATION
�° ,.�. � Sfale Fortn 43708 (R6 / <-Oe) . '
Prescnbed by ihe Dapartment of Local Govemment Fnanca
File Mark
. ormation contained in this documeni is CONFIDENTIAL pursuant to IC 6-1.1-12•9 and IC 6-1.135-9. 1i—t 7-� --
�
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o/ the county where
the p�operty is located.
See reve�se side lor additional instruction and quali(cations.
ra�
applicant the sole legal or
� or
�'es ❑ No �
name on record Is difterent than that o( applicant, indicate beiow
must have 6een buvina on confracf af
Ir`4 � � �
FlLING�DATES: �j �� I� �
1) Real property: During the 12 months before May
11 of the year�the dedu�tion is to be effective.
2) Mobile homes assessed under 1.C.6-i-1-7;
between January 15 and March 31 0l the year
the deduction.is to tie;eNective.
i someone omer man spouse,
whom
`
Address of conVaU selle Is Ne property in queslion:
�(o - l3 - a3 - y p0-b D � 3 9�- oc� ❑ Real property ❑ Mobile home (I.C. 6•1-7-7)
Taxi 'strict Key number / Legai description Record number Page number
� o 03- o0 3��-oc�.
Is the property used and occupied primarity for Assessed value o( the property as of March 1, current year (may not
hisRier residence? exeeed 3144,000)
❑ Yes O No
Was the applicant 65 years of age or more on December 31 of the year poes fhe combined annual adjusted gross income of the applicant and any
prior to the curtent year? individuals sharing ownership exceed 525,0007
ed by a surirving, unmarried spouse, what was
fime of death?
�e you filed for any other deductionsl
you filed for
❑ Yes
❑ Yes
❑ No
age at
❑ Yes ❑ No
$
I/We certify under penalty of perjury that the above and foregoing information is true and correct and lhat the applicant was a resident
of Indiana and owner o( the aforementioned property on March 1, 20 _
Signature of
of appli�ant r ri (� �Address of authorized representative