HomeMy WebLinkAboutAge_Blakea n� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE� COUN7Y TOWNSHIP v�tt
'���� REQUESTING DEDUCTION FROM ASSESSED VALUATION
�> .' State Fortn 43708 (R6 / 4-0a)
Prescnbed by Ihe Department of Local Government Finance
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Iniortnation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9. �����
INSTRUCTIONS: FILING DAT
To be filed in person or by mail with the County Auditor o/ fhe county whe�e 1) Real property: Durin the 12 months before May
the property is located. 11 0/ the year t/i��dJctl�n�i��6e elfective.
' 2) Mobile homes assessed under I.C.6-1-1-7;
See reverse side for additional instruction and qualific ,' behveen Januaq�.�5 and M�[�ch 31 of the year
the deduction is�to b �e�'ctivei
NTY AUDITOR
Name of applicant (owner nfract b er)
W�.Nw �M.� T �L.J'' � �" .q
Is applicant the sote legal or equitable owner? If No, what is his/h r xact share or interest? If owned with someone other than spouse,
� indicate with whom
Q Yes o
I( name on rewrd is difierent than that of ap icant, indicate below
Name of contrad eller (applirant must have been buying on contract af least one (1 f year)
Address of wntra t seller Is the property in queslion:
❑ Real property ❑ Mobile home (I.C. G7-1-n
'ng s t Key number / Legal description Record number Page number
-(�v3 i-o�
Is the properry used and occupied primarity tor Assessed value o( the property as of March 1, current year (may not
hisRier residence? ezceed 5144,000)
❑Yes ❑No
Was ihe applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of the appiicant and any
prior to the current year? individuais sharing ownership exceed 525,0001
❑ Yes ❑ No ❑ Yes ❑ No
Applicant's date of birih (month, day, yearJ Source of Income Amount of Ineome
�- $
I( filed 6y a surviving, unmarried spouse, what was the spouse's age al $
the Ume of death?
TOTAL $
Have you filed (or any other Aeductions? If Yes, what deductions? -
❑ Yes
Have you filed for dedudions in any�other couniy? If Yes, what county?
❑ Yes
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicanl was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant Signature ot authorized representative (by executed Powe� olAttomeyJ
:ess of appliwn��(/ Address of authorized representative
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