HomeMy WebLinkAboutAge_Creek°� rt���'� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNTV TOWNSHIP veart
'i � '� REQUESTING DEDUCTION FROM ASSESSED VALUATION
�� ,•. i State Fortn 43708 (R6l a-04)
Presuibed by ihe DeDartment of Local Govemment Pinance
�..,,rtnation cootained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-359.
File Mark
INSTRUCTIONS: FILfNG DATES:
To be �led in person or by mail with the CountyAuditor of the county where �
the property is locafed.
See reverse side fo� additional instruction and qualifications.
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1) Real property: During the 12 months 6elore May
11 0/ fhe year the deduction is to 6e e/(ective.
2) Mobile homes assessed underl.C.6-1-1-7;
6etween January 15 and March 31 of the year
the deduction is to 6e ef/ective.
Name of applicani (owner or conVact buyerJ
� L/1 �
Is appliqnt the wle leg I or equitabie owne(? If No, what is hislFier act share or interest? If owned with someone other than spouse,
- indicate with whom
❑ Yes ❑ No
It name on rewrd is difterent than Nat of applicant, indicate below �
Name of contract seller (appficant must have been buying on contrect at least one (1J year)
Address of conVact seller Is the property in quesfion:
Real property ❑ Mobile home (I.C. 67-1-�
Taxing district Key number / Legal description Record number Page number
�`1Y1 do5 -0 3 7 - �
Is the property used and occupied primarily for Assessed value of the property as of March 7, current year (may not
hislher residence? exceed 3144,000)
❑ Yes ❑ No
Was Ihe applicant 65 years of age or more on December 31 oi ihe year poes the combined annual adjusted gross income of the applicant and any
prior to the wnent year? individuals sharing ovmership exceed 825,000?
❑ Yes ❑ No � �'es ❑ No
ApplicanPs date of birth (month, day, year) Source of Income Amount of Income
/ � $
If filed by a surviving, unmarried spouse, what was the spouse's age at $
the time of death?
TOTAL $
Have you filed (or any ofher deductions? If Yes, what deductions? .
❑ Yes O No
Have you filed for deductions in any other county? If Yes, wha[ county?
❑ Yes � No
I/We certify under penalty of perjury 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 applicani Signature of authorized representative (byexecuted PowerofAttorney)
�ess of applicant � Address of auNOrized representative