HomeMy WebLinkAboutAge_Heldta� rt.••�} AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�r ''� REQUESTING DEDUCTION FROM ASSESSED VALUATION
> ,��� .° State Fofm 43708 (R6 / 4-0a)
� Prescribed by Ne Department ol Local Govemment Finance
Information contained in this document is CONFIDENTIAL pursuanl to IC 6-1.1-12-9 and IC 6-1.135-9.
INSTRUCTIONS:
To 6e �led in person or by mail with the CountyAuditor of the county where
the property is located.
See reverse side for addifional instniction and oualifications
COUNTY TOWNSHIP YEAR
G�
File Mark
FIL��E��
1) e 1 p p months 6efore May
of t e year the deduction is fo 6e effecfive.
2) Mobi/e�q�r s1a�e��underl.C.6-1-1-7;
behvee J�Auary 15 and March 31 oJ the year
the deducfion !s t�e�Nective.
/%�,
Name of applicant (owner or contrect buyer) V NTY AUD17�R
� GIBSON COU
Is applicant the sole legal or equitable o eR If No, what is his/her exact share or interest? If owned with someone other than spouse,
indirate with whom
es ❑ No
If name on record is diRerent than that of applicant, indipte below
Name of contract seAer (applicant must have been buying on contract at least one (1J year)
Address of contract seller Is the property in queslion:
❑ Real property -❑ Mobile home (I.Q G74-�
�ng district Key number / legal description Record number Page number
Q� -- ��f - 3 5-E�
Is the property used and occupied primarily for Assessed value of the property as of March 1, wrrent year (may not
hislher residence? exceed 5144,000)
es ❑
Was the applicant 65 years of age or more on December 37 e year poes the wmbined annual adjusted gross income o( lhe appliqnt and any
prior to the current year? individuals sharing ownership exceed $25,000?
es ❑ No ❑ Yes ❑ No
Applicanl's
$
Have you fied (or any oNer deductlons? If Yes, what deductions?
❑ Yes ❑ No
Have you filed tor deductions in any other county7 If Yes, what counryl
❑ Yes ❑ No
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 applicant Signature of authorized represenfative (by executed Power ofAttomey)
C��i/%`�/V /C.0 -
.ress of applicant Address of authorized representative
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