HomeMy WebLinkAboutAge_Sheridan.� rt.�•
} AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�' ` REQUESTING DEDUCTION FROM ASSESSED VALUATION
ti��w / State Form 43708 (R4 / 16-01 �
Prescribed by Ihe Department ol Local Govemment Finance
INortnafion contained in this document is CONFIDENTIAL pursuant to IC 6-1.7-12-9.
INSTRUCTIONS:
To be fled in person or by mail wifh the County Auditor of the county where
the property is /ocated.
See reverse side for additional instruction and qualifications.
COUNTY TOWNSHIP YEAR
ile M
FILINGDATES: AUG 1 4 ZOOZ
1) Real property: During the 12 montF,s before May
11 0/ the ye r he deducti n i�o 6e eflecti e.
2) Mobile ho asse �����"(��� �,,¢� - - ,
between , n���nd r" Ff�3�t�o%pe year
the deduction is to 6e effective.
Name of applicant (owner or contract 6vyer) .
Is applicant the sole lega or equ'rfable ovme If No, what is hisAier exact share or interest? If owned with someone other than spouse,
indicate with whom
es ❑ No
If name on rewrd is diRerenl than ihat of applicant, indicate below �
Name of contrad seller (applicant must have been buying on ton(ract at least one (7J yearJ
P.ddress of contrad seller Is ihe property in question:
❑ Real propeAy ❑ Mobile home (I.C. 6-1-1-n
�ng district Key number / Legal desuiption Rewrd number Page number
��=1=3 =:E�O 3�'15_ Oo
Is the pr perty used and ocwpied primarily for — Assessed value of Ihe property as of March 1, wrrenl year (may not
hismer residence? exceed %69,000)
es ❑ N
Was the applicant 65 years of age or more on December 31 of year Dces the com6ined annual adjusted gross income of the applicant and any
prior to ihe wrtent year?
❑ Yes ❑ No
Have you filed for deductions in any oUier county? If Yes, whal county?
❑ Yes ❑ No
I/We 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 lhe aforementioned property on March 1, 20 _
' na re of a li t Signature of authorized representative (by executed Power ofAttomey)
t
,-wdre • licant '� Address o(aulhorized representafive
�� I � 6�ia�•�n4� 6 9