HomeMy WebLinkAboutAge_Riley�°_�•� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courm TOWNSHIP � YEAR
` i° REQUESTING DEDUCTION FROM ASSESSED VALUATION
�° ! State Fortn a370B (R614-0c) � - � �1 ;
•• Prescribed by iha DepaAment ol Lowl Govemment Finance d J
. rmation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.735-9.
i e ar
JUN 0 7 2007
INSTRUCTIONS: FILING DATES:
To be filed in person or by mail with the CountyAuditor o/the county where
the propeRy is located.
C eal property ❑ Mobiie home (/.C. 6•14-7)
Taxing district Key number / legal description Record number Page number
� � a - - �1 = aa (� c,�
Is the property used and occupied primarily for Assessed value ot the property as of March 1, c ent year (may not
his/her residence? exceed 3744,000J
s ❑ NO
Was the appliwnt 65 years ot age or more on Decem r 31 of Ihe year poes the combined annuat adjusted gross income of the applicant and any
priw to the curtent year7 individuals sharing ovmership exceed 525,000?
es ❑ No O Yes ❑ No
Applicant's date of birth (
/
Have you Lled for any other dedudions? If Yes, what deductlons7
s ❑ No
Have you filed for deductions in any other county7 If Yes, whal county? .
❑ Yes o
I/We certify 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 the aforementioned property on March 1, 20 _
Signature of appiicant SignaNre of authorized representative (by execu(ed Power o7AttorneyJ
. /
es of applicant qddress of aulhor¢ed representative
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