HomeMy WebLinkAboutAge_OatesR.�
a,_, _� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
" REQUESTING DEDUCTION FROM ASSESSED VALUATION
�> .� State Fortn 43708 (R6l G-Oa) �
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Prestnbed by ihe Depanment of Local Gwemmant Fnance
�rtnation contained in this document is CONFIDENTIAL pursuant to IC 6•1.1•12-9 and IC 6-1.1•35-9.
INSTRUCTIONS:
To be �led in pe�son o� by mail with the CountyAuditor of the county where
the propeRy is located.
See reverse side for additional instruction and quali(cations.
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FILINGDATES: p"' ��p�TOR
1) Real property��yq'�f����s before May
11 of the ye�� i3ie deduction is to be effective.
2) Mobile homes assessed under I.C.6-1-1-7;
between January 15 and March 31 of fhe year
the deduction is to be eBective.
Name of applicant (owner or con t buyer) "
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Is applicant fhe sole legal or equitable owner? Ii No, what is hisRier exad share or interest? If owned with someone other than spouse.
' , - indicate with whom
OYes ❑No
If �ame on record is diBerent than that of applicant, indicate below
Name of contract seller (applicant musf have been buying on contracf af leasf one (1J year)
Address of wnVad seller Is tha property in question:
� Real property ❑ Mobile home (I.C. 6-1-7-7)
Tauing district Key number I Legal description Record number Page number
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Is lhe prope used and cupied primarily for Assessed value of the property as of March 1, current year (may not
hisfier resi ence? exceed 3144,000J
❑ Yes ❑ No
Was the applican[ 65 years o( age or more on December 31 of the year poes the combined annual adjusted gross income of the applirant and any (
prior to the wrtent yearl individuals sharing ownership exceed 525,0007
�J'es ❑ No ❑ Yes ❑ No
AppliwnPs date o( birth (month, day, year) Source of Income Amount of Ineome
% - �� ��1`.e,�"�-c'a"f 5 �l ! 3 �---
If filed by a surviving, vnmarried spouse, whal was the spouse's age at $
the time of death?
TOTAL S
Have you filed for any other deduclions? If Yes, what deducUons?
❑ Yes ❑ No
Have you filed for deducUons in any other county? i( Yes, what county9 I
❑ Yes O No
ilVJe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident I
of Indiana and owner of the aforementioned propeRy on March 1, 20 _
Signature of applicant Signature of authorized representative (by executed Power ofAttomeyJ
1Y.�4-Q1
ress of applicant Address of aulhorized representative
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