HomeMy WebLinkAboutAge_DewigS__�� t AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
� REQUESTING DEDUCTION FROM ASSESSED VALUATION
� / State Fortn 43108 (RO / 1P91)
�•� Presvibed by Ihe DepartmeN ot local Govemmenl Finance
malion contained in Nis dowment is CONFIDENTIAL pursuant lo IC 6-1.1-12-9.
INSTRUCTIONS:
To be filed in person or by mail wifh the County Auditor o/ the county where
the p�operty is /ocated.
See reverse side for additional instruclion and qualiBcations.
Name of p nt (owner or contract buy
�• --�
Is applirant the sole al or equilable owneR If No, a is hislher ezaG share or interest?
es ❑ No
If name on rewrd is diRerenl tha ihat of applicant, indiwte below
Name of contrad seller (applicant must have een buying on contract at least one (1� year)
` l�
Address of contrad seller
Taxi distric n Key number / Legal description
and ocwpied primariy for
.r reswence �
es ❑ No
the applinnt 65 years of age or more on December 31 of the year
to the current year?
��3 �� ❑Yes ❑No
canYs date of birth (month, day, year)
fded by a surviving, unmartied spouse, what was
e time of death?
you uiea �or any
you filed for deductions in any other county?
age at
-t?Yes ❑ No
COUNTY TOWNSHIP YEAR
_ _ ; " ' _ '—.v �'�
J � -� �
; . � � _ ,File,Mark ��
FILING DATES: F� u 1 � ZQQZ
1) Real property: Dunng the 12 montF,s before May
11 0l the year the deduction s to be eHective.
... , ,.�--, -._
2) Mobile hoine's'assessedunde�LC;6-1-1J;
befween January 15 and H1a�cb 31 0/ the year
the deduction is to be e/%ctive.
If owned with sameone
indicate with whom
Is Ihe property
spouse,
❑ Real proDerty ❑ Mobile home (I.C. 61-7-n
Rewrd number Page number
�Lssessed value of the property as of March 1, current year (may nof
exceed 569,000)
Does ihe wmbined annual adjusled yross income of fhe applicant and any
individuals sharing ownership exceed 525,000?
� ❑ Yes ❑ No
Source of I come Amount of Income
/] i n �,, ii $
If Yes. what
'�
TOTAL I $
❑Yes ❑bl� � �
IlVJe certify under penalry of perjury that ihe above and foregoing information is true and correct and that the applicant was a resi-�
denl ot Indiana and owner of lhe aforementioned property on March 1, 20 _
representative