HomeMy WebLinkAboutAge_Pruitt•� `��h��a AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courriv TOWNSHIP YEAR
' RE�UESTING DEDUCTION FROM ASSESSED VALUATION
e/
��' Slate Form 43708 (R / 9�6)
)�,—� "'" Presrsibetl by Ne State Boartl of Tax Commissioners
Inbrmation contained in this document is CONFIDENTIAL pursuani to IC 6-7.7-72-9. �-� �File MOrk
� � �y
INSTRUCTIONS FOR FILING: �� � J `s..,� • "'
To be liled in person or by mail with the County Auditor of the county where the property loca- � O(�
ted during the 12 months before May 77 0! the year the deduction is to be ef(ecfive. n R,„ 20
Deductions lor mobile homes not assessed as real property must Iile between January 75 an6'P �
March 31. �,J /���
See reverse side for additional instruction and qualilications. �//` ,�� l��`- � ��`�
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nameon
� or contract buyer) (1 �� 1�
L%� � �� � T,
W `���k- l./ \
or equitable%�{ner? If No, what is hislher exaci share of interest?
❑ Yes ❑ No �
ihan that of applicant, indicate below
contrad seller (applicant must have been 6uying on contract at least one (1) year)
Address of contraci seller
�ing disirict
��
Is the property used and occupied primarily to
his/her residence?
Was ihe applicant 65 years of age or more on
prior ro the curreni year?
etl by a survmng, i
time of deaih?
ie you filed for any
re you filed br ded
-
spouse.
any
Key number / Lege
c� i 3
❑ Yes ❑ No
December 37 ot the year
was the spouse's age ai
❑ Yes ❑ No
1 Someon0 O�hBf Ihan SPOUSB,
whom
I descnpuon Hecortl number I Page number
-�3o��c�
Assessed value of the property as of March 1, curreni year (may not
exceed $21.000)
❑ Yes ❑ No
Does ihe combined annual adjusted gross income of the applicant and any
individuals sharing ownership ezceed 520.000?
❑ Yes ❑ No
$
❑ Yes ❑ No �
I/VJe certify under penalty of perjury ihat the above and foregoing information is true and correci and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 19
pture of applicant SignaNre ot authorized represeNative (by executed Power o/AttomeyJ
X o �� -�
Qi
F�i�%�� �Y%�:��
of auihorized representative