HomeMy WebLinkAboutAge_Edrington= ae�"-'4,� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
� � ,, REQUESTING DEDUCTION. FROM ASSESSED
(� VALUATION State Form 43708 (1-90) Prescribed by the
° State Board of Tax Commissioners
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Instructions for filing:
To be filed in person or by mail with the County Auditor of the County where the
property is located during the 12 months before May 11 of the year the deduction
is to be effective. Deductions for mobile homes not assessed as real property
If name on record is different than that of applicant, indicate below:
County � Township
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�y p 1 1991
�gSON
Year
If owned with someone other than
spouse,'indicate with whom. �
contract seller (Applicant must have been buying on contract at least one (1) year.)
Address of contract seller
Key
Description
Is the real property use¢ and occupied primarily
for his/her residence? � yes O no
Was the applicant 65 years of age or more on
Dece ,er 3t of the year prior to the current year?
yes O no
Does the combined annual adjusted gross
income of the applicant and any individuals
sharing ownership exceed $k5;9d0?
❑ yes ❑ no %J. O a �-
Have you filed for any other deductions?
Have you filed for any deductions in any other county?
—o;U � Page No.
A'ssessed value of the property as of March 1, current
year (may not exceed $19,000).
ApplicanYs date of birth �, �, /
/
If filed by a surviving, unmarried spouse, what was the
spouse's age at the time of death?
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If yes, what
0
I If yes, what county?
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
cant was a resident of Indiana and owner of the aforementioned property on March 1, 19
�nature Authorized Representative (by executed Power of Attorney)
,�/l ,Ua _ �,
: �
ress of Applicant . „„ Address of Representative
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