HomeMy WebLinkAboutAge_Besing"� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
y- ; REQUESTING DEDUCTION FROM ASSESSED VALUATION
' State Fwm 43708 (R3 / &00)
'•'• Presuibetl by the State Board of Tac Commissroners
In ortnation contained in this document is CONFIDENTIAL pursuant to IC G7.1-72-9.
1NSTRUCTIONS FOR FILING:
To be filed in person or by mail with the County Auditor of the county where the property is loca-
fed during the 12 months before May 11 0/ the year the deduction is to 6e ef(ective.
Deductions (or mo6ile homes not assessed as real praperty must file beiween January 15 and
March 31. '
See reverse side (or addi6onal instrucGon and qualifications.
YEAR
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MAY 0 8 20�3
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GIBSOPI COUr� � Y ����T�R ,
Name of applicant (ownerorcon6act buyer) . .
R �
Is appiipnt lhe sole legal or equitable owneR If No, what is hisRi r xaG share or interest? � If owned with someone other than spouse,
indicate with whom
es ❑ No .
If name on record is dfierent than that of appliwnt, indipte below
Name of contrad seller (applicant must have been buying on conlract at least one (i) year) ,
Address of conVad seller
�cin9 distrid Key number / 1e9a1 description Record number Page number
� � f �'1-�-- - .0-�- '�t^�jO
Is the real prope sed and occupied Assessed value of the property as of March 1, wrte�t year (may not
primarity for hislher residence7 exceed 569,000) �
❑Yes ONo
Was the applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of the applicant and any
prior to tha current yeaR � individuals sharin9 ownership exceed $25.0009
❑ Yes ❑ No ❑ Yes ❑ No
Applipnl's date
_ $ �.
I( filed by a surviving, unmarried spouse, what was lhe spouse's age at $
the time of death7 - ,
TOTAL $
Have you filed for any other dedudions7 if Yes, what dedudions?
❑ Yes ❑ No
Have you filed for dedudions in any other county? If Yes, what couny!
❑ Yes ❑ No
I/VJe certify under penalty of perjury thal the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
' nature applicant Signature ot authorized representative (by executed Power ofAttamey)
/
.lress of pplipnt � Address of aulhorized representative
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