HomeMy WebLinkAboutAge_Lewis (2)S_, ,n.••�,��, AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
COUNTY TOWNSHIP YEAR
' REQUESTING DEDUCTION FROM ASSESSED VALUATION
�O ,�„ � State Portn 43708 (R614-04) � � ���
Presuibed by the Depariment of Lowl Govemment Finance r"`
1 Mark' y
�ormation contained in this document is CONFIDENTIAL pursvant to IC 6-1.1-72-9 and IC 6-1.1-35-9.
INSTRUCTIONS: FIUNG DATES: �UL J(i !;j(; j
To be filed in person or by mail with the CountyAudito� of the county where 1) Real property: D�j?� e 12 �o�ths before May
the property is located. 11 of the year the deB n`is fo3e eNective.
2) Mobile horr�ggg��s��de�:l��-d p� 7;
See reverse side fo� additional instruction and qualifications. behveen January 15 and March 31 of the year
the deduclion is to be effective.
applicant Ne sole legal'or equitable owner? If No, what is hislher exact share or interesl? If owned with someone other ihan spouse,
' indicate with whom
��Yes ❑ No �
If name on record is diflere than that of appliwnt, indicate below
must have been buvina on contract af least one
of conVad seller
property
❑ Real property ❑ Mobile home (I.C. 6-14-7)
Rewrd number Page number
Is the property usetl antl occupletl pnmanry tor Assessed value ot the property as of Ma¢h 1, curtent year (may not
his/her residence? exceed 5744,000)
s ❑No �� ��
Was the applicant 65 years of age or more on Dec ber 31 of fhe year poes the combined annual adjusted gross income of the appliwnt and any
prior to the current year7 individua�s sharing ownership exceed $25,0007
es O No ❑ Yes o
ApplicanPs date of birth (
$
If filed by a surviving, unmarried spouse, what was the spouse's age at $
the time of death?
TOTAL $ � /� /lfl
you metl ror any
you rned tor deducuons in any
� Yes
❑ Yes
IMIe 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 _
3nalure of appliwnt Signalure of authorized representative (by executed Power ofAttomey)
S� e n /�, i
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