HomeMy WebLinkAboutAge_Ashby. ej"'"v AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
'1 ' REQUESTING DEDUCTION FROM ASSESSED VALUATION
2 State Porm 43708 (R / 9-96)
�`,�4���, Prescrihetl by the State Boartl ot Tas Commissioners
Information contained in ihis document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
COUNTV I TOWNSHIP I YEAR
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INSTRUCTIONS FOR FILING: �,,�A ZOUQ
To be )iled in person or by mail with the County Auditor ol the county where the property is loca- I InR 2�
ted during Ihe 12 months before May 11 0/ the year the deduction is to be eftective. �
Deductions (or mobile homes not assessed as real property must lile between January 75 and � ��
March 37. ���7� )� �'—�
See reverse side !or additional instruction and qualifications. f ��: SO"� •-: ���T '�"��?�� l
Na e of a liram (owner or contract buyer) ,
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Is ap licant the sole legal or equitable owneR If No, what i s/her exact share of interest? If owned with someone other than spouse,
indicate with whom
�❑ No
If name on record is different than that of applicant, indicate below
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Name of contrac seller (applicant must have been buying on contrect at least one (7J year)
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Address of tract seller
,���i g di i Key number / Legal description Record number Page number
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Is the property used and occupied primari for Assessed value of the property as of March 1, current year (may nof
his/her residence? exceed $27,000)
es ❑ No ❑ Yes ❑ No
Was Ihe applicant 65 years ot age or more on December 37 of Ihe year poes ihe combined annual adjusted gross income of Ihe applicant and any
prior to the current year? individuals sharing ownership exceed 520,000?
❑ Yes ❑ No
ApplicanYs
$ o00
If filed by a surviving, unmarried spouse, what was the spouse's age at $
Ihe time of death?
TOTAL $
Have you filed for any other deductions? If Yes, what deductions?
❑ Yes Y�rvo
Have you filed for deductions in any other county? If Yes, what county?
❑ Yes II�iVo
II/We certify under penalty of perjury that the above and foregoing information is true and correct and thai the applicant was a resi-
� dent of Indiana and owner of the aforementioned property on March t, 19 i
Signature ot applicant I Signature of authorized representative (by executed Power olAttorney) ;�
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�dress of applicani � �o h 38 y Address of authorized representative
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