HomeMy WebLinkAboutAge_WallaceAFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, counrv TOWNSHIP r�na
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S�w / State Fmn 43708 (R7 / SOB)
Presmhd by the Departrnen� of Lod Gwemmeni Finance
F rk
ation conWined in this dowment is CONFIDENTIAL oursuant to IC Cr1.1-12-9 and IC 61.135-9
INSTRUCTIONS: FILING DA�.+j Q ZOO�
To be filed in person or by mail with the County Auditor of the county where 1) Real property: During the 12 months before June
the property is located. 11 of th he � on is to be effective.
2) Mo6ile me�sess�I.C.6-1-7-7;
See reverse side for additional instruction and qualifications. be�YB�NB�;� a c 31 of the year
the deduction is to be effective.
Name
buyer)
Is applinnt the sde legat or equitable owneR I( No, what is
❑Yes ❑No
If name on remrd is diRere�l than that oF applicant, indinte below
mus! have been
for
residence?
Was the applicant 65 years of age a more on uea
priw to Ihe wrrent yearl
Applicant's date oi birth (month, day, year)
7 on con
number
Z� � �
�Yes ❑ No
mber:31 of the year
�Yes ❑No
age at
❑Yes ❑ No
any other cwnt�?
exact
one (7) year)
If owned vriM someone other Ihan spouse,
indicate vrith whom
Is the property in question: �
❑ Real property ❑ Mobite home (I.C. Et-7-n
Recad number Page number
• wJ �n � I 1
sessed value of the property as ot March 1, curtent year
Dces the combined annual adjusted gross income
individuals sharing orwnership exceed 525,0007
of Income
whatdeducGans?
wunry?
$
$
TOTAL $
�y
❑Yes ❑No
Amount oi Income
s-
❑Yes ❑No I
IMIe certify under penalty of perjury that the above and foregoing inf��**��r��n is true and correct and thal the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
SignaW re o ap t SignaW re ot authorized representative (by executed Powe� W AttomeyJ
� �',�� l'G���� - -
authorized representalive
V_ l.1