HomeMy WebLinkAboutAge_Perkins° rt• t AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�' `" REQUESTING DEDUCTION FROM ASSESSED VALUATION
S � SWta Fortn 43708 (R614-04) '
�� • Prescnbed by the Department of Local Gwemmant Finance
rtnation contained in this document is CONFIDEN7IAL pursuant to IC 6-7.1-12•9 and IC 6-1.1-359.
INSTRUCTIONS:
To be filed in person or by mail with the CountyAudifor of the county where
the p�operty is located.
See reverse side for additional instrucfion and qualifications.
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the sole legal or equitable owne(?
❑ No
name on rewrd is
conVad
the property used and
No, what is his/her exact share or
on
one
number / Legal description
�] Yes ❑ No
Was the applicant 65 years of age or more on De e er 31 of Ihe year
prior Po the current year?
❑ Yes ❑ No
ApplicanCs date of birth (month, day earJ
If filed by a surviving, unmarri spouse, what was the spouse's age at
the tlme of death?
you tiletl tor any olher detlucUi
you filed tor deduUions in any
❑ Yes O No
i
COUNTY TOWNSHIP YEAR
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FILING DATES: JUN Q 6 ZOOJ
1) Real property: Du 'ng the 12 months be(ore May
11 of the year the�ctle,n�s�o 6e e/fective.
2) Mobile h��s�sse�ed underl.C.6-1-1-7;
befween January �f5���n'dK12m.�r,�3l�af the year
the deduction is to be e/%ctive.
I vAth someone olher ihan spouse,
with whom
Is the property in question:
�Real property ❑ Mobile home (I.C. 6-7-7-7)
Assessed value of the property as of March i, current year
exceed 3144,000)
Does Ne cOmbine0 annual atljUSteA gro55 fnCAr
individuats sharing ownership exceed 525,0007
� Yes �( No �
IIVJe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a residenL
of Indiana and owner of the aforementioned property on March 1, 20 _
re of applicant � Signature of authorized representative (by execufed Powe� o7Attomey)
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Address of authorized