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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cour+rv TOWNSHIP vEna
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S srare F«m a3�oa (rt7 i sas>
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Fresrntee Ur me Department m �oca� cwemment Finance
il a
�nalion contained in Ihis dowment is CONFIDENTIAL oursuant to IC 6-1.1-12-9 and IC 61.1-35-9.
INSTRUCTIONS: FILING DATES:
To be filed in person o� 6y mail with the County Auditor of the county where 1) Real prc��rEy: �u6ng �%12 months before fune
the property is located. 11 of the year the deduciion is to be effective.
2)Mobile��J� sas�ass�dunderl.C.6-1-1-7;
See reverse side lor additional instruction and qualificafions. betweerYJA�iu�y 15 a� March 31 of the year
�h81�'8�'ntiO�tSN� �D�el��(JF�.
�
conLad
on
contract seller (applicant musf
what
❑No
appGpnt, indicate
Taxing districl
�,a t� �
. f�ssessed value of ihe property as of March 1, arrent year (may /rof
exceed S 144.0001
Yes �No
�mbec3l the year poes the combined annual adjusted gross inmme of the applicant and any
individuals sharing ownership exceed 525,000?
es ❑No �Yes ❑No
.
$
❑Yes ❑No I
I/We cerlify under penalty of perjury that the above and foregoing inf�rt*+�r��n is We and wrreci and thal the applicant was a resident
of Indiana and owner of ihe aforementloned property on March t, 20 _
3nature of applicant Signature of authorized representative (by erecufed Power olAttomeyJ
RSl
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