HomeMy WebLinkAboutAge_Blaizeej—"o AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�'` t REQUESTING DEDUCTION FROM ASSESSED VALUATION
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State Porm 43708 (R / 9-96)
�'}���• Prescribed by the State Board ot Tax Commissioners
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.7-72-9.
INSTRUCTIONS FOR FILING:
To be (iled in person or by mail with the County Audito� o/ the county where the property is loca-
ted during the 72 months belore May 17 of the year the deduction is to be ellective.
COUNTY TOWNSHIP YEAR
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APR 1 1 2000
Deductions !or mobile homes not assessed as real property must lile beRVeen January 75 and
March 31.
See reverse side !or additional instruction and qualilications. CI?SON COU TY AUDITOR
Name of applicani (owner or contract buyerJ
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A F A!� Ai2 �
Is applicant the sole legal or equitable owner? If No, what is his/her exact share of interest? If owned with someone other than spouse,
indicate with whom
❑ Yes ❑ No
If name on record is diHerent ihan that of applicant, indicate below
IName ot contract seller (applicant must have been buying on con(racl a( least one (7) year)
(Address of coniract seller
�ing isirict Key number / Legal descripiion Record number Page number
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Is ihe property used and occupied primarily for Assessed value of ihe property as of March 1, current year (may not
his/her residence? exceed $21,000)
❑ Yes ❑ No ❑ Yes ❑ No
Was the applicani 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 ro ihe arrent year? individuals sharing ownership exceed 520.000?
❑ Yes ❑ No
ApplicanCS
at O O $ �p
the time ot death?
TOTAL $
Have you filed tor any other deductions? If Yes, what deductions?
d%�'F pl�,_¢Q C3� Yes ❑ No r
Have you filed for deductions in any other county? If Yes, what county?
Y�
❑ Yes No �
1lWe certify under penalty of perjury that the 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, 19
Signature of applicam Signature of authorized representative @y executed Power olAttomey)
,,.idress of appliwni Address of authorized representative
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