Age_Powers.K,.
AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cour+TV TOWNSHIP v�ux
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S�w � Slate Farm 43708 (R7 / SO6)
PresvLed by the Deparmient of Local Gwemment Finance
File Mark
�nation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9. g
INSTRUCTIONS: FILING DA qe �/
To be fled in person o� 6y mail wifh the County Auditor ol the county where l) Real pr�erty.�Bu�j't��72'R�on s before �une
the property is located. 11 of the year fhe deduction is� be eHecfive.
2) Mobile home��es�e`��AI.C.6-1-1J;
See reverse side for additional instruction and qualifcations. between January 15 and March 31 0/ the year
the deduction f�;lo7ke ef(�If�e,
�ne of applicarri (owner or contrdd 6uyerJ �
�
appGcant Ne sole legal or equ table owneR If No, v
es ❑No
name on record is different tha Mat oF applicant, indicate
Narne oi contract seller (applicanf must have D
Address af contract seller
Taxirx� disUict
Is the roperty used d ocapied Prim rity fw
his/h dence?
Was Me appiicant 65 years of age or mae o� ��
prior W fhe current yeaR
share w interest?
om m�tract at least one
If owned vriN saneone
indicate with whom
Is the properry
spouse,
eal property ❑ Mobile home (I.C. G7-7-n
Legal description ��a � R number Page number
��a F-��
'. a Assessed vafue o�f t�he property as of March 1, curtent year (may nof
� ❑No
ember3� of the year
�Yes ❑No
dicanPs date of birth (month, day, year)
ed by a surviving, unmartied spouse, whai was tl
Gme of deaN? -
1�
you
any other deductions?
age at
❑Yes ❑No
any other count�!�
annual adjusted gross incw
nvnershio exceed E25,000?
Source of Income
whatdeductians?
$
$
TOTAL $
�f Ne app�cant antl any
❑Yes ❑No
Amount of Income
❑Yes ❑NO I
I/We certify under penalty of perjury tha[ the above and foregoing infc+�**+=}��n is Irue and correct and that lhe applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Po��-=—
3 d 3 6 5 /050 '✓ ��NSD%/��
of authwized
or authorized
A