HomeMy WebLinkAboutAge_Barkhurst.� R.,
3__ AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
° REQUESTING DEDUCTION FROM ASSESSED VALUATION
ti ! State Fortn 43708 (Rd / 10-07 )
Prescn'bed by Ihe Departmeni ot Local Govemment Finance
Intortnation wntained in this document is CONFIDENTIAL pursuant to IC 6-7.7-72-9.
INSTRUCTIONS:
To 6e (led in person or by mail with the County Auditor o/ the county where
the property is located.
See reverse side for additional instruction and qualifications.
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FILING DATES.MAY 2 ?OOY
1) Real perty: Duri g t 12 montY,s b fore May
11 0/ e year ed on is be � ective.
2) Mo e} T.. 1-1-7;
befwe �a }3 r�d�a��c�i �1 bf the year
fhe deduction is to be ef(ective.
Name oi a li nt (owner or contracf 6uyer)
• � �. — - ---- -�
Is applican the le legal or equitable own . If No, what is hislher exact share w interest? If owned with someone other than spouse,
indicate with whom
es ❑ No
If name on record is difteren[ than thal of appliwnt, indicate below
Name of contracl seller (applicanf must have beon buying on contract at least one (7) year)
Address o( contrad seller Is the property in question:
�ap��Ol� aDI �WV•��l' � ❑RealproDeAy ❑Mobilehome(I.C.61-1-n
�ng district Key number / Legal descrip6on Record number Page number
� � ��-- C9- _r3- _pp.-3�`I'1_OO�
Is the property used and occupied primariy (or Assessed value of the property as of March 1, current year (may nof
hisRier residence? exceed $69,000J
es ❑ No
Was the applicant 65 years of age or more on December 37 0( th year poes the combined annual adjusted gross income of the applicant and any
prior to fhe wrrent year? indi�riduals sharing ownership exceed 525,000? � �
s ❑ No p Yes LJ�l7o
ApplinnYS date of
was Ihe spouse's age at $ —
the Gme of death?
TOTAL $
Have you filed for any other deductlons? If Yes, what deductions?
❑Yes ❑No
Have you filed (or deductions in any other county? If Yes, what 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 _ � c)
Signature of applicant Signature of au�horized represenlative (by executed Power o(AttomeyJ �
'� `�_. /
ss of appticant Address of aulhorized representative � �
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