HomeMy WebLinkAboutAge_Kissel�. AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, c NTM TOWNSHIP r�
REQUESTING DEDUCTION FROM ASSESSED VALUATION �
S i State Fortn 43708 (R7 / SOB)
.«.
Pmsvibed M 1tre Deparb�em of Lod Goverruneni Finance
File Mark
.��ormation contained in this document is CONFIDENTIAL pursuant to IC E1.1-12-9 and IC 61.1-35-9.
INSTRUCTIONS: FILIN�T�� �
To be (led in person or by mail with the County Auditor of the county where 1) R pro nths before June
the property is located. 1 i of the year the deduction is to be eflective.
2) Mo6ile h�$E $s�s���]nder I.C.6-1-1-7;
See reverse side !or additional instruction and qualifications. between January 75 and March 31 ot the year
the dedustien,is to 4s eNective.
Name of applicant (owrl�
�
Is apptipnt the sole leg
If name on record is difl
Narne oi contract selier
' \
Address o( contract sell
DmPertY use
r residence?
�--V �
�Tes ❑No I
han that of applipnt, indicate below
must
�
ocapied Primarily for
exact share or inte2st?
on contract af least one
�Yes_ ❑No
ihe appiicant 65 years of age w rtrae on December3l� of the year
lo the arrenl year? .
�Yes ❑No
icanPs date oi birth (month, day, year)
If filed by a surviving,
the Iime of death?
you filed for a�ry
`
married spouse, what was ihe spouse's age at
you filed fw deduc6ons in any other
I with someone other tnan spouse,
with whom
Is the property in question: - �
�eal pmperty ❑ Mobile home Q.C. Gt-1-�
ed value of ihe property as of March 7, cun
' 8144, 0001
ie combined annual adjusted gross incane
ials sharing ownership exceed 525,000?
Source of Inwme
� $
$
TOTAL $
whatdeduc6ons?
what county?
year
any
❑Yes ❑No
Amount of Income
�-c�� a
DYes �lo I
I/We certify under penalty of perjury lhat the above and foregoing info��t��n is Irue and cortect and thai the applicant was a resident
of Indiana and owner of Ihe aforementioned property on March 1, 20
gnatura of ap�rant Signature of authorized representative (by execufed Power ofAttomey)
i ai rc' �iti-�.-- d. ,
L/.. t r 1� _i.� %n/ G, �%/ tl�
': ;
of authorized