HomeMy WebLinkAboutAge_Scottdd•`��'�at AFFIDAVIT OF PERSON, 65 YEARS OF�AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED
' VALUATION State Form 43708 (1-90) Prescribed by the
`�•�• �• State Board of Tax Commissioners
Instructions for filing:
To be filed in person or by mail with the County Auditor of the County where the
property is located during the 12 months before May 11 of the year the deduction
is to be effective. Deductions for mobile homes not assessed as real property
mustfile betweenJanuary 15and March 31. See reverse foradditional instructions
and qualificatioris.
County Township Year
File Mark
�,Q
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Applica t( w er or contract bu ) � ����
� .J � �eeT cufl�� �-/ S
Is applicant the sole legal or If no, what is his/her exac are or If owned with someone other than
equitable owner? �yes O no interest? spouse, indicate with whom.
6�
If name on record is different than that of applicant, indicate below:
Name of contract seller (Applicant must have been buying on contract at least one (1) year.)
Address of contract seiler
ng isir Key Number/Legal Description Record No.
C� l�✓ �� _.� _ �D-d-� PagA No.
Is the real property used and occupied primarily Assessed value of the property as of March 1, current
for his/her residence? O yes O no year (may not exceed $19,000).
Was the applicant 65 years of age or more on ApplicanYs date of birth
December 31 of the year prior to the current year?
O yes O no If filed by a surviving, unmarried spouse, what was the
spouse's age at the time of death?
Does the combined annual adjusted gross ce o income Amount of income
income of the applicant and any individuals � L��. _
sharing ownership exceed $15,000?
O yes ❑ no
Total
Have you filed f r any other deductions? If y�sucLions? „,
2 S . ��°—"'(�
Have you file for any deductions in any other county? If yes, what county?
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I/We certify under penalty of perjury that ihe above and foregoing information is true and correct and that the appli-
cant was a resident of Indiana and owner of the aforementioned property on March 1, 19
S'��nnature Authorized Representative (by executed Power of Attorney)
. ;
Address of Applicant " Address of Representative °•�
�7 ���� �.
�°'- / 66 G