HomeMy WebLinkAboutAge_Lindyi �_ n•�• '; AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
' REQUESTING DEDUCTION FROM ASSESSED VALUATION
�° � State Fortn d3708 (R6! 4-0d) �
Prescnbed by Ihe Departmen� 0/ Lowl Govemment Finance
�rmation wntained in this dowmeni is CONFIDENTIAL pursuant to IC 6-1.1-12•9 and IC 6-7.1-35-9.
INSTRUCTIONS:
To 6e filed in person or 6y mail with the CountyAuditor of the county where
the property is lowted.
See �everse side (or additional instruction and qualifications.
COUNTY I TOWNSHIP I YEAR
FlLING DATES: �' �LJ'
1) Real properf�iingg ��]�r�onths 6efore May
i] o/ the year the deduc b'N(s to 6e effective.
2J Mobile hortr�� asses� d under l. C.6-1-1 J;
behveen January°�5ar(tl.Ma�ch 31 01 the year
the dd88c11pnvs�o�e�,eftective.
AUD17na
Name of apD����t (owner or conVact buyer) , -
C?`'��r"�^�y �
Is applicant the sole legal or equitable owne If No, what is ' er exact share or interest? If owned with someone other than spouse,
' indicate with whom
es ❑ No -
I( name on record is diRerent fhan that of applicant, indicate below
Name of contract seller (appllcant must have been buying on cont2ct ef leasf one (7f year)
Address of contratt seller Is the property in question:
� Real property ❑ Mobile home (I.C. 6•1-7-7)
Taxing ' rici Key number I Legal description Record number Page number
G�.�a-�-Q� a�-os -3a - `,'oo-cn�, i89-oa�
Is the property used and occupied primarily for Assessed value of the property as of March 1, current year (may not
his/her residence? exceed $144,000)
❑ Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the wrrent year9 individuals sharing ovmership exceed 525,0007
❑ Yes ❑ No ❑ Yes ❑ No
Applicanl's date of birth (month, day, year) Source of Income Amount of Income
�00,6 �-�.G`«,�,�. � l � �i 7
If filed by a surviving, unmarried spouse, what was the spouse's age at $
the 6me of death?
TOTAL $
Have you filed for any other deductions? If Yes, whal deduc6ons?
❑ Yes ❑ No
Have you filed (or deduUions in any other county? If Yes, what wunlyT
❑ Yes ❑ No
INVe ceRify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of lhe aforementioned propeRy on March 1, 20 _
Signature pliwnt Signaiure of au�horized representative (by executed Powei ofAttomeyJ
��ess of applicant Address of authorized represenlative
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