HomeMy WebLinkAboutAge_DeffendallS4 �_. .• � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courm TOWNSHIP renR
` REQUESTING DEDUCTION FROM ASSESSED VALUATION
�' ,��� .� SUte Fortn 43708 (R6 / 4-OC) � �
Prescnbed by ihe Depanmant of Local Govemment Finance
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�rmatlon coniained in this document is CONFIDENTIAL pursuant to IC 6-1.'i-12•9 and IC 6-1.1-35-9.
INSTRUCTIONS: FILINGDATESJUN O 5 Z�O%
To 6e �led in person or by mail with the County Auditor of the county where
the propeRy is located. �
See �eve�se side lor additional instruction and qualifications.
1) Real prope�ty During the 12 months before May
11 of the year �� de�e��f is to be e(fective.
2) Mobll�homes,�sses �ed�under 1. C.6-14 J;
6ehveen January��i3 aiid4A�TF�31 of the year
tbe deduction is to be effective.
Name of appli t(owner o� contract buye�) �
WNV \
Is applicant the ole legal or equitable owner? ( No, whal is his/her exaci share or interest? If owned with someone other than spouse,
' . � indicate with whom
❑ Yes ❑ No
If name on record is diBerent ihan ihat o( applicant, Indicate beiow ,
Name of contract seller (applicant must have been buying on contract at leasf one (1J year)
Address of conVact seller Is the property in question:
❑ Real property ❑ Mobile home (/.C. 6•74-7)
Taxing districi Key number / Legal description Record number Page number
� �6 y - oa- oao.a��-c�
is the property used and occupied primarily for Assessed value of the property as of March 1, current year (may not
his/her residence? exceed $144,000J
es ❑ No
Was the applicant 65 years of age or more on December 31 0� year poes the combined annual adjusted gross income of the appiicant and any
prior to the current year? individuals sharing ownership exceed 825,0001 ��
es ❑ No O Yes l�'No
AppliwnYs date of birth (monfh, day, year) � Source of Income Amount of Income
� $
It filed by a surv'rving, unmarried spouse, what was the spouse's age at $
the tlme of deaih?
TOTAL $
Have you filed for any oiher deductions? If Yes, what deductions7
p Yes O No
Have you filed (or deductions in any other wunty? If Yes, what counry?
❑ Yes ❑ No
I/We certify under penalty of pery'ury that the above and foregoing information is lrue and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March t, 20 _
Signature of appliwnt I Signature ot authorized representative (by executed Power olAttomeyJ
D
re of applicant Address of auihorized representalive
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