HomeMy WebLinkAboutAge_Nelsondj �'"a AFFIDAVIT OF PERSON� 65 YEARS OF AGE OR MORE�
` t REQUESTING DEDUCTION FROM ASSESSED VALUATION
.' I,
State Form 43708 (R / 9-96)
�" e Prescribetl bY ihe State Board ol Tax Cammissioners
Information contained in this documeni is CONFIDENTIAL pursuam to IC 6-7.7 -12-9.
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor o) the county where the property is loca-
ted during the 72 months be)ore May 71 0! the year the deduction is to be ellective.
Deductions for mobile homes not assessed as real property must lile between January 15 and
March 31.
See reverse side lor additional instruction and qualilications.
COUNTV TOWNSHIP YEAR
File Mark
Name of applicani (owner or contract buyerJ
s
�' �- �o�-1,c.e, . - � � �� ;� �
Is applicant the sol egal or equitable o r? If No, what is his/her exact share of interesL otdned'vri someone%tY�er than spouse,
indicate with whom
❑ Yes ❑ No r E B 18 200
If name on record is different than ihai of applicant, indicate below !' � n �
/ �/� �ts��� r;/��Li�-�-�-"'
Name of contraci seller (applicant must have been buying on con�iacf af leasr one (�) year) -�""""'
Address of contraci seller
in irict Key number / Legal description Record number Page number
� oo�-Dl�y�-a�
Is the property used and occupied pri rily for Assessed value of ihe property as of March 7, current year (may not
hismer residence? exceed 527,000)
❑ Yes ❑ No ❑ Yes ❑ No
Was the applicani 65 years of age or more on December 37 of the year poes the combined annual adjusted gmss inwme of the applicant and any
prior to the current year? individuals sharing ownership exceed 520,000?
❑ Yes ❑ No
Applican�'s date ot birth (month, day, yearJ Source oi Income Amount of Income
$ 1 1. 8�5'D
If filed by a surviving, unmarried spouse, what was the spouse's age ai �
the time of death? — -�
TOTAL $
Have you filed for any oiher deductions? If Yes, what deductions?
❑ Yes ❑ No
Have you filed tor deductions in any other wunry? If Yes, what counry?
❑ Yes ❑ No
IlWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 19 _
SignaWre ot applican SignaWre of authorized representative (by executed Power otAttomeyJ
�i i
.� s of a pli nt Address ot authorized representative .
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