HomeMy WebLinkAboutAge_Fickel3_�.� : AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
� � REQUESTING DEDUCTION FROM ASSESSED VALUATION
��N � State Form 43708 (R4 / 7 P-01 �
Presrribed by Ihe Depanment ot Loca� Govemmenl Finance
�matlon wnGined in this dowment is CONFIDENTIAL pursuant lo IC 6-1.1-12-9.
INSTRUCTIONS:
To be filed in person or by mail wifh the County Auditor o/ the county where
the property is located.
See reverse side Ior additional inst�uction and qualifications.
FILING DATES: nn'
1) Real property: D�i the ��EMR�s 6elore May
11 of fhe y r the deduction i to be eHecfive.
2J Mobile h es assess u rl.C.6=7-1 ;
6etween ad) year
thededucfl���t%�Ne'c�ve�!��TOR (
Name of applicant (owner or contracf buyer) .
� - -�
Is applicant �he sole legal or equitable owner? If No, what is hisAier exact share or interest? If owned vrith someone other than spouse.
indicate with whom
❑ Yes ❑ No
If name on record is ditferent than that of applicant, indirate below
Name of contrecl seller �applicant must have been buying on contract at least one (1J yearJ
Address o( contrad seller Is the property in question:
� Real property ❑ Mobile home (I.C_ E1J-n
�g c�stricl Key number / Legal description Record number Page number
// �
(1/ � - - - - �6=�=
Is the property used and ocwpied p arily for Assessed value of the property as of March 1, wrrenl year (may nof
hismer residence? exceed 569,000)
� oNo a���
Was the applicant 65 years of age or more on December 31 of the year Dces the wmbined annual adjusted gross income of the applicanl and any
prior to the wrtent year? individuals sharing oxmership exceed 525.000?
L7Yes ❑ No ❑ Yes ❑ No
ApplicanYs dale of birth (month, day, yearJ Source of Income Amount of Income
- $
If fJed by a surv'rving, unmarried spouse, what was the spouse's age at $ � -�
Ihe Ume of death?
TOTAL $
Have you filed for any other deducUons? If Yes, what deductions?
❑Yes ❑No
Have you filed for deductions in any other county? If Yes, what county?
❑ Yes ❑ No
I/We certify under penalty of perjury that ihe 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 _
SignaNre of applicanl � Signature of authorized representative (by executed Power o/Attomey)
� � �'
ess of applicant - ' Address of authorized representative