HomeMy WebLinkAboutAge_Kuehlingy� _ n•� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
` j° REQUESTING DEDUCTION FROM ASSESSED VALUATION
�O � State Fortn 43708 (R614-0a) '
�• Prescribed by Ihe Depanment ot Local Gavemmeni finance
rmaUon contained in lhis document is CONFIDENTIA� pursuant to IC 6-1.�-72-9 and IC G7.13S9.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where
the property is located.
See reverse side Ior additional instruction and qualifications.
COUNTY TOWNSHIP YEAR
� � J �J
JUN jFi�e Mar�IF
FILING DATES: �2 ��
1) Real properiy: Dunng�ihe 12 months before May
11 of fhe ��6tba �aludfon lS,1DIbe E(/ective.
2) Mobile homes assessed under I.C.6-1-1-7,�
between January 15 and March 31 of the year
the deduction is to be e/fective.
Nai e of aIlplicant (owner or contract buyer� �
YJ O� %
Is appliwnt the sole " al or equitable owneh If No, t is hislher exact share or Interest? I� owned with someone other than spouse,
' indicate wiih v+hom
❑ Yes ❑ No
If name on record is different than ihat of applicant, indicate below
Name of contrect seller (applicant must have been buying on contrect at least one (1) year)
Address ot conVaU seller Is lhe property in question:
❑ Real property ❑ Mobile home (I.C. 6•1•1-7)
Taxing i trict Key number / Legal description Record number Page number
Q��� a� �a -04-�o3-r.n�. is3�o�7
Is ihe properry used and occupied primarity for Assessed value of the properry as of March 1, curtent year (may not
his/her residence? exceed 5744,000)
Yes O No
Was the appliwnt 65 years of age or more on Decem er 31 of the year poes 1he wmbined annual adjusted gross income of the applicant and any
prior to fhe current year7 individuals sharing ownership exceed 525,0001
Yes ❑ No ❑ Yes No
$
Have you filed (or any other deductions? If Yes, what deducUons?
❑ Yes ❑ No
Have you filed for deductlons in any other counry? If Yes, what wunty?
❑ Yes ❑ No
I/We certify under pena�ty of perjury that the above and foregoing informalion is true and correct and that lhe applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature o licant� ���n� Signature of authorized representative (6y ezecuted Power o7Attomey)
�
res� �� �ni �� ��'L Address of aulhorized representative
' rGS�. 6
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