HomeMy WebLinkAboutAge_PennerS_rt•� ti AFFIDAVIT OF PERSON� 65 YEARS OF AGE OR MORE� CoUN7Y TOWNSHIP YEAR
�° ° REQUESTING DEDUCTION FROM ASSESSED VALUATION
ti•» / State Form 43708 (R4 / 1P01)
Prescribed by ihe Depanmen� ot Local Govemmenl Finance
File
1�. ..nation contained in [his document is CONFIDENTIAL pursuant lo IC 6-7.1-12-9.
INSTRUCTIONS:
To 6e liled in person or by mail with the County Auditor of the county where
the p�operty is located.
See reverse side for additional instruction and qualifications.
�. (owner or wnVact buyer)
Is appiicanl the sole legal or
I( name on rewrd is difleren
Name o( contracl seller (app
P.ddress of contraU seller
No, what is his/her exact share or interest?
❑ Yes ❑ No �
ihan that of applicant, indicate below
/ � �
U �
property used and ocwpied primarily for
r residence?
the applicant 65 years of age or more on
to the wrrent year?
year)
on contract at least one (1) yearJ
FILING DAT� � � � �
1 J Real property: L�� tl�e/1�2 q�p¢ff;s 6efo2 May
11 of the year the duchffn fsi'l�i�tie effective.
2) Mobrle h es assessed u�e� I.C.6-1-1-7;
betwee nua nd reh 3�r �,of t� year
the de c eltectiSe'-��',�-� J
Util't i,Upf�Or'��
If owned wiih someone
indicate with whom
M� � S�-e
� �
��y��
Is tl -
I
L�
�=p,- prj �� Real property
dion - Record number
��
Assessed value of the property as of March
exceed $69, 000)
spouse,
Mobile home (I.C. 67-7-�
Pagenumber
wrrent year
❑ No
he year poes the combined annual adjusted gross inwme of the applicant and any
individuals sharing ownership exceed 525,000?
❑ No
�
If fJed by a surviving, unmarried spouse, what was Ihe spouse's age at
Uie time of death?
Have you filed for any
you
any other county?
❑Yes ❑No
❑Yes ❑No
❑ Yes ❑ No
Source of Income Amount of Income
$
�
TOTAL $
If Yes, what deductions?
If Yes, whal county?
I/We certify under penalty of perjury that the above and foregoing information is true and correct and thai the applicant was a resi-
dent of Indiana and owner of the aforemenlioned property on March 1, 20 _
aNre of applicant Signature of authorized representative (by executed Power o(Attomey)
of applipnt �
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