HomeMy WebLinkAboutAge_Ivy° n• 3 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
' iQ REQUESTING DEDUCTION FROM ASSESSED VALUATION
ti � SWta Fortn 43708 (R6 / 4-Oaj � '
Prescnbed by the Department ol Local Gavemmeni Finance
nformaUon contained in this document is CONFIDENTIAL pursuant to IC 6-t.t-12-9 and IC 6-1.7-359.
INSTRUCTIONS:
To be filed in person or 6y mail with the CountyAuditor of the county where
the property is located.
See reverse side !o� addifional insVUCtion and qualifications.
COUNT`! I TOWNSHIP I YEAR
FILING DATES:
1) Real propeR�'.DriHrtcj t�e (J� montfis be%re May
11 0! the year the deduction is to be eHective.
2) Mobile homes assessed,underl.C.6-1-1•7;
between January;l5 e�March 31 of the yea�
the ���dr° �� �o�be. etife�f'weR
Name of applicant ( er or conUacf buyer) �
Is applicant the sole I gal or equitable owner? If o, hat is his/her exad share or interest? If owned with someone other than spouse,
' , indicate with whom
O Yes � No
If name on record is diRerent than ihat o� applicant, indicate below
Name of contrad se0er (appl/cant must have 6een buying on contract atleast one (7J year)
Address of contract seller Is the property in questlon: .
❑ Real property ❑ Mobile home (I.C. 6-7-7-7)
T ng di rict K_ey numboter / Legal descriplion O a 7 Record number Page number
d!O � -/7 -dLCJ-��.975
C� �D �09 �1 S -� c�
Is the property used and occupied prim rily for Assessed value of the property as of March 1, curtent year (may not
hisRier residence? exeeed 3144,000)
❑ Yes ❑ No •
Was the applicant 65 years ot age or more on December 37 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the anent year? individuats sharing ownership exceed 525,0001
❑ Yes No O Yes � No
Applicanfs date of birth (month, day, year) Souree of Income Amount of Income
_ � _ -�— $
If filed by a surviving, what was the spouse's age at $
the 6me of death?
TOTAL $
Have you filed��for any oNer deductions? I( Yes, what deductions?
� Yes o
Have you filed (or deductions in any other county? If Yes, what count� '
❑ Yes
I/We certify under penalty of perjury that the above and foregoing informalion is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned propeRy on March 1, 20 _
Signature of applicant � Signature o( authorized represeniative (by executed Power o7AttomeyJ
/
ress of iwnt Address o( auNOrized representative �
b� �� � i -� oh rn�
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