HomeMy WebLinkAboutAge_Coburn• rt•� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
'� n� iQ REQUESTING DEDUCTION FROM ASSESSED VALUATION
�� r State Fortn 43708 (R6 / 4-04)
Prescnbed by Ne Department of Local Govemment Finance
In(ormation contained in ihis document is CONFIDENTIAL pursuant to IC 6-7.7-12-9 and IC 6-1.135-9.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where
the propeRy is located.
See reverse side fo� additional instruction and qualifications.
COUNTY TOWNSHIP YEAR
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FILING DATES: � �'"""'r� �
1) Real property: Dunng j¢e�J2�ogth,�,�ore May
11 0( the year the dedYl�t�i�� R3 �� ctive.
2) Mobi/e homes assessed under I.C.6-1-1-7;
between January 15 a`frd�Maro�i3�Yof the year
the deduction is to be eflec�fl e.
GIBSON COUNfii' A_ Blfic�g
Name of ap ' ant (owner or contract buyer) �
Is applicant the sole legal or equitable own I( No, what is hislher exact share or interest? If owned with someone other than spouse,
' indicate with whom
Yes � No
I( name on record is diRerent t an that of applicant, indicate below
Name of contract seller (applicant must have been buying on contract at least one (i) year)
Address of contract seller is lhe property in questlon:
Real properry � Mobile home (I.C. 6-7-7-�
�g district Key number / Legal descripiion Rewrd number Page number
�� ��a- �� -�
Is ihe property used and occupied.primarily for Assessed value of the property as of March 1, current year (may not
hishier residence? exceed 3144,000)
Yes ❑ No
Was the applicant 65 years of age or more on December 37 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the current year? individuals sharing ovmership exceed $25,000?
Yes ❑ No ❑ Yes ❑ No
ApplicanPs date of birth (month, day, yearJ
Have you �led for any other deductions? If Yes, what deductions?
Yes ❑ No , pS.
Have you filed for deductlons in any other county? If Yes, what wunty?
❑ Yes No
1/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 oEapplicant Signature of aulhorized represeniative (by executed Power ofAttomeyJ
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....,,ress ot applicant Address of authorized represenlative
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