HomeMy WebLinkAboutAge_Catt��r _�•• 4 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUi4TION
S ,��� � SWte Fortn 43708 (R6I4-0d) �
Prescnbed by the Department oi Local Govemment Finance
�rtnation contained in this document is CONFIDENTIAL pursuant to IC 6-7.1-12-9 and IC 6-�.7359.
INSTRUCTIONS:
To be �led in person or 6y mail with the CounfyAuditor of the county where
the propeRy is located.
See �everse side for additional instruction and qualifications.
COUNTY TOWNSHIP YEAR
�
File Mark
MAY 2 3 2007
FILING DATES:
1) Real propeRy: Dunngjhe'�2 mont�i s before May
11 of tbe year �b eductio�is�% � Nective.
2) Mobile homes a���s��43HhfB�N.�jf�d;
6etween January 15 and Ma�ch 31 0/ t e year
the deductron is to be eNective.
Name of applicant (owner or contracf buyer) , � I
� �
Is applicant the sole legal or equitable owne(.� If No, what is hislher exad share or Interest? I( owned wiN someone other than spouse,
' indicate wiih whom
Yes ❑ No
if name on record is difierent than that of applicant, indicate below
Name of contract seller (applicant musf have been buying on conVacf at least one (1) year)
Address of wnVact seller Is the property in quesGon:
eal property ❑ Mobile home (I.C. 6-1-7-7)
Tapng disVict Key number / legal descrip6on Record number Page number
� d6-�a-�b-ioo-000, o -o:,t
Is the property used and occupied primarify tor Assessed value of the property as of March 1, cunent year (may not
hisfier residence? exceed 5744,000)
es ONo � a �c�OO
Was the appliwnt 65 years of age or more on Dece ber 31 of the year poes the wmbined annual adjusted gross inwme of the apPlicant and any
prior to the current year? individuals sharing ownership exceed 525.0007
Yes ❑ No ❑ Yes ❑ No
Appliwnl's date of birth (
was the spouse's age at � $ ��
the fime of deathl
TOTAL $ � 5 �'
Have you filed for any other deductions? If Yes, what deducdons?
❑Yes o
Have you filed for deducUons in any other county? If Yes, what counry7
❑ Yes o
I/We certify under penalty of perjury that the above and foregoing information is irue and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _ •
Signature of applicant Signature of authorized representative (by ezecuted Power olAttomeyJ
�
ress o applicant Address of aulhorized representalive
1 R c� �.