HomeMy WebLinkAboutAge_Willis�. F AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S State Form 43708 (RS / 603)
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Prescribed by the Department of Loral Govemment finance
InfortnaUon contained in ihis document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
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RUCTIONS: FILING DATES: y fII,
To 6e filed in person o� by mail with the County Auditor o/ the counry where 1) Real propeA�}.�DunngQh�'1Y�onths before May
tbe property is Ixated. 11 of�he year the deduc�n is to be eHective.
2)Mo�4 home�as�ess�edunder�11C.�Y-1-7;
See reverse side /or additional instiuction and ualifications. beah.��§if�2rtd�ir.y�15'��'HAarc�-37-±0/ the year
Q the dedi�i�i is'fo�6�'e`ffSctroeOR I
Name oi appiicant owner or cont2ct buyer) ) '
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Is applicant Ne sole legal or equitable owne(t If at is his/her exact share or inte If owned with someone other than spouse,
indirate with whom
❑Yes ❑No
If name on record is different than ihat oi applicant, indinte 6elow
Name of coniract Seller (applicant must have been buying on conhact at least one (1) year)
Address of conVact seller Is the property in queslion:
eal property ❑ Mobile home (I.C. 6-7-7-n
a�nng district � Key number / Legal description Record number Page number
��,�r nol 5d-/- : _���,�_ � i
�he property used and occupied prim ty for Assessed value of the property as ot March 7, curtent year (may nof
her residence? exceed S 744, 000)
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 applicant and any
prior to the current year? �/ individuals sharing ownership exceed 525,000?
L✓JYes ❑No ❑Yes ❑No
ApplicanPs date of birth (monfh, day, year) _ Source of Ineome Amount of Income
/- � - �/ g S $
IF filed by a surviving, unmarried spouse, what was ihe spouse's age at $
Ne fime of deaN?
TOTAL $ �
Have you filed for any olher deductions? If Yes, what deducfions?
❑ Yes L�1't�fo
Have you filed (ar deduMions in any other county? I( Yes, what count�?
� Yes No
I/We 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 _.
Signature of applicant , Signature of authorized representative (by executed Power of Attomey)
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dress of plicant Address of auNorized represenWtive