HomeMy WebLinkAboutAge_Gullic• n.n � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
'" '� REQUESTING DEDUCTION FROM ASSESSED VALUATION
S� .� State Fortn 43708 (R6 / 4-04)
Presaibed by Ne Department of Local Govemment Finance
� �.
In(ormation contained in this document is CONFIDENTIAL pursuant to IC 6-1.7-72-9 and IC 6-7.1-359.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where
the propeRy is located.
See reverse side (or additional instniction and quali(cations.
UNTY TOWNSHIP YEAR
APR 2 5 IT005
FILING DATES��
1) Rea/ prop g��g�12 months 6efore May
11 o��r � dedu y�! is to be eHective.
2) Mobile hom ��sk KHI¢ rl.C.6-1-1-7;
6ehveen January 15 and Ma� 31 0l the year
the deduction is to be effective.
Name of applicant (owner or cont2cf buye� -- - �
�, �����r�-�-�-9 i �-• -
Is applirant lhe sole legal or equitable ovmel? If No, what is his/her exact share or interest? If owned with someone other than spouse,
indicate wiih whom
Yes ❑ No
I( name on record is difterent than that of applicant, indicate below
V
Name of conlract seiler (applicant must bave been buying on cont2ct at lea ne (1) year)
Address of conUacl seller Is lhe property in quesdon:
Real property ❑ Mobile home (I.C. 61-1-n
'ng disUicl Key number / Legal description Record number Page number
i � :C���-all3 -
Is ihe property used and occupied primariy tor Assessed value of fhe property as of March 7, current year (may not
hismer residence? ezceed 5144,000)
❑ No
Was ihe applirant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross inwme of the applicant and any
prior to the current year? individuals sharing ownership exceed $25,000?
es ❑ No ❑ Yes ❑ No
Appliwnt's date of birth (month, day, year)
$
Have you filed for any other deductions7 If Yes, what deductions?
❑ Yes �"FJo
Have you filed for deductions in any other county? It Yes, what county?
❑ Yes �o
IlWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signatur pplicant Signature of authorized representative (by executed Power ofAttomey)
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.ress o pplicani . �( - Address of authorized representalive
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