HomeMy WebLinkAboutAge_Barberdj rt'"o AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
= REQUESTING DEDUCTION FROM ASSESSED VALUATION
e .
Sta;e Form a3708 (R / 9-96)
�"�' PreStnbed by the Siate eoard of Tav Commissioners
Information rAntained in this document is CONFIDENTIAI pursuam to IC 6-1.t-72-9.
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor ol the county where the pioperty is loca-
ted during the 72 months belore May 71 of the year the deduction is to be elfective.
Deductions tor mobile homes �ot assessed as real property must lile beRveen January 75 and
March 37.
See reverse side !or additional instruction and qualilications.
COUNTV TOWNSHIP ,YEAR
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� � ._ File�MarSi1.1/�
NOV 0 2 1a97
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GIBS0:4 "_ . . . �
Name of appliwni (owner or conhact buyerJ
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Is applirant the sole legal or equitable owner? tl , what is his/her exact share of interest? If owned with someone other than spouse,
inditate with whom
❑ Yes ❑ No
If name on record is diHerent than ihat of applicant, indicate below
Name of contract seller (applicant must have 6een buying on contract at /east one (�) year)
Address of coniract seller �
ing districi Key number / Legal description Record number Page number
�D =�-- D _ : - =/-�-9=��
Is the propeny used and occupied primarily for Assessed value of the property as of March 1, current year (maynot
hisfier residence? exceed $27,000)
❑ Yes ❑ No ❑ 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 curreni year? individuals sharing ownership exceed 520.000?
❑ Yes ❑ No
ApplicanYs date of birth (m th, day. yeai) Souree ot Ineome Amount of Ineome
� $
If filed by a surviving, unmarried spouse, what was the spouse's age at $
ihe time of death?
TOTAL $ � Q�d
IHave you filed for any other detluctions? If Yes, what deductions? '
❑ Yes G' No
Have you filed for detluctions in any other counry? If Yes, what county?
❑ Yes f�lo
IIWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 7, 19
ISi at of applicant Signature of authorized representative (byexecuredPOwero7Attomey),
'�-,'� �- '�°`-�-��
ess o( applicant � Address of authorized representative