HomeMy WebLinkAboutAge_Brown•n � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATtON
S / State Form 43708 (RS / 6-03)
,a.
Ptescribed Dy ihe Departrnent of Lopl Govemment Finance
Infortnation conWined in this document is CONFIDENTIAL pursuant to IC E7.1-12-9.
COUNTY TOWNSHIP YEAR
File Mark
�RUCTIONS: FILING DATES: ��
To 6e filed in person o� by mail with the Counry Auditor of the county where 1) Real propert Dud� t� 1�tn . s� May
the property is located. 11 0/ tAe year the edu�on �s o e e�echve.
2) Mobile homes asS�ps�d�en�-1-1-7;
See reverse side for additional insVucfion and qual�cations. between January 13an rc�h of the year
the deducti�is to be effecti�e?
If name on record is
Yes ❑ No
that of aonlican
exaa snare w
oi conVact seller (applicant rhust Aave baen buying on contract at least one (7) year)
B
residence?
�Yes ❑ No
s the applicant 65 years o( age or mwe on December 31 of the year
�r to the cuvent year?
�Yes ❑ No
dicant's date of birth (
spouse's age at
6me of death?
Have you filed for any
❑ Yes
you filed for deductions in any oiher
GI3SON
ii owned witn someone
indicate with whom
AUDITOR
spouse,
the property in questlon:
❑ Real property ❑ Mobile home (I.C. 6-1-1-n
Record number Page number
ltssessed value of the property as of March 1, curtent year (may not
exceed S74a,000�
Does the com6ined annual adjusted gross income of the applicant and any
individuais sharing ownership exceed 525,000?
❑ Yes ❑ No
�
❑Yes �lNo �
I/We certify under penalty of pe�jury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned propeRy on March 1, 20 _.
gnature of applicant _ Signature of authorized representativa (by executed Power o7Attomey)
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Address of auNorized