HomeMy WebLinkAboutAge_Bryant��� t AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�' ' = REQUESTING DEDUCTION FROM ASSESSED VALUATION
� � ! 51ate Fortn 43708 (R4 / 10.07 )
• Prescnbed by Ne Department of Local Govemment Finance
InfortnaUon contained in �his dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS:
To be filed in pe�son o� 6y mail with the CountyAuditor of the county whe�e
the property is /ocated.
See reverse side for addifional instruction and qualifications.
COUNTY TOWNSHIP Y
O � �
il Ma
FILING DATES: �AY 9 2002
1) Real perty: Dunn th 2 montF,s 6etore May
11 0/ ar du n is to e e ective.
2) M !e(hg3���J / ���-�'
behveen Janua '�S'��rYd�fb�rcb� Pf the year
the deduction is to be effective.
Name of applica ner or conVact buyer) �
f
� C — _'" `J
Is applican sole legal or equitabl owner? f No, �a is his�her ex ct share or interest? If owned with someone other lhan spouse,
indicate with whom
O Yes ❑ No
I( name on rewrd is diRerent than ihat of appliwnt, indicate below
Name of contract seller (applicant must have been buying on contract at least one (1) year)
Address ot wntract seller Is the property in question:
�Real property � Mobile home (I.C. 67-1-n
� �ng 'sVict Key number / Legal descrip6on Record number Page number
' � �D - - - - - - - :o��
Is the property used and ocwpied primarily for Assessed value of the property as of March 1, current year (may not
hislher residence? exceed $69,000)
❑ Yes � No
Was the applicant 65 years of age or more on December 31 of the year poes the combined annuai adjusted gross income of the applicant and any
prior to the current year? individuals sharing ownership exceed $25,000?
❑ Yes ❑ No ❑ Yes ❑ No
Applicant's date of birth (monfh, day, yearJ
$
Have you filed tor any olher deducUons? If Yes, what deduclions?
/y � �Yes ❑ No
Have you filed tor deductions in any other county? If Yes, what wunty?
❑ Yes No
IlWe certiTy under penalty of perjury that ihe above and foregoing information is true and correcl and thai the applicant was a resi-
dent of Indiana and owner of ihe aforementioned property on March 1, 20 _
SignaNre of appliqnt Signature of au�horized representative (by executed Power a(Attomey)
^ G��r �
ress appGCant � / Address of authorized representa6ve
X D �S. ���� � �,� � N, Y