HomeMy WebLinkAboutAge_Berrya•°'°4' AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
a� � 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
must file between January 15 and March 31. See reverse for additional instructions
and qualifications. .
Applicant (Owner or contract
County � Township� Year
NOY 2 0 1996
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AUDiT9R °
Is applicant the sole I or If no, what i�l is/her exact share or If owned with someone other than
equitable owner? yes ❑ no interest? spouse, indicate with whom.
If name on record is differeni than that of applicant, indicate below:
Name of contract seller (Applicant must have been buying on contract at least one (1) year.)
Address of contract seller
Is the real property used, �and occupied primarily
for his/her residence? ,u yes ❑ no
Was th pplicant 65 years of age or more on
Dec ber 31 of the year prior to the current year?
yes ❑ no
Does the combined nual adjusted gross
income of the ap cant and any individuals
sharing owne ip exceed $15,000?
O yes � no
Have you filed for any other deductions?
Have you filed for any deductions in any other county?
i Record No.
—� Q Page No.
Assessed value of the property as of March 1, current
year (may not exceed $19,000).
ApplicanYs date of birth
the
spouse's age at the time of death?
Source of income Amount of income
Total
If yes, what deductions?
If yes, what county?
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appii-
cant was a resident of Indiana and owner of the aforementioned property on March 1, 19
Signature Authorized Representative (by executed Power of Attorney)
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of Applicant 1
Address of
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