HomeMy WebLinkAboutAge_Kinsman.+' °'n
3_ � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�" � ° REQUESTING DEDUCTION FROM ASSESSED VALUATION
� •w � State Fwm 43708 (R4 / 10-Ot )
Prescribed by ihe Department ol Local Govemmenl Finance
In ortna6on contained in this dowment is CONFIDENTIAL pursuanf 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 insfruction and qualifications.
couNrr
FILING DATES:
TOWNSHIP YEAR
c
Fil �k�
J
1) Real propeAy: O�ig th�f�{�jWrjths be(ore May
11 of th ar fhe deduction Ps (D 6e eHective.
2) Mo6il omes asse ed de� I.C.6-1-1-7;
6etw arch of e year
the ded�i�SfJSf Ig� {y��rna
Name of applitant ( i�r contract buyerJ
(_ _/ Ill S/I'1 R n/-1 � �. S�
Is applicanl the soie legal or equitable ovmer? if No, what is hisRier exact share or interest? If owned with someone other than spouse, .
indicate with whom
� ❑ No /�
I( name on record is diflerent ihan that o( applicant, indiwte below
Name oi contrad seller (applicanf must have been buying on confract at least one (7) year)
Address of contrad seller Is the property in question:
t� ��
�Real property ❑ Mobile home (I.Q 6-1-1-�
T ring district Key number / Legal description Record number Page number
�G...� ✓• D_/6 = o-��S�7=o,0
Is Ne property used and occupi rimarily for Assessed value of the property as of March 1, current year (may not
hismer residence? —/ exceed 569,000J
t�'S'es ❑ No
Was the applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of the applicanf and any
prior to Ihe curtent year? �� individuals sharing ownership exceed $25,000?
i�Yes ❑ No ❑ Yes ❑ No
ApplicanYs date of birth (month, day, yearJ Source of Income Amount of Income
/ S s, $
If filed by a surviving, unmarried spouse, what was Ihe spouse's age at $
the fime of dealhl
� TOTAL $
Have you filed for any other deducGons? If Ye� deduclions?
�jYes ❑No +�-�--� •
Have you filed (or deductions in any other counTy? If Yes, what county?
❑Yes �No
I/We certify under penalty of perjury that the above and foregoing informatiori is true and correct and that lhe applicant was a resi-
denl of Indiana and owner of ihe aforemenlioned property on March 1, 20 _
Signature of applicant SignaNre of authorized representative (by executed PowerolAttomey)
��� �
ess of applicant Address of authorized representative