HomeMy WebLinkAboutAge_ConklinJ`�dj ��na AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE� Cour�v TOWNSHIP YEAR
� '� °,. RE�UESTING DEDUCTION FROM ASSESSED VALUATION
• State Porm a3708 (R / 9-96) O�
f'�,�,�'�' Prescribed by Ne State Board of Tas Commissioners
Intormation containetl in this document is CONFIDENTIAL pursuant to IC 6-1.7 -12-9. �gFile Mark
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INSTRUCTIONS FOR FILING: _ _5 r ( ;i =F �
To be filed in person or by mail with the County Auditor o/ the county where the property is loca- '��
ted during the 72 months before May 77 of the year the deduction is to be eflective. �P 2 � Z���
Deductions tor mobile homes not assessed as real property must lile between January 75 and
Ma�ch 37. �'
1/
See reverse side lor additional instruction and qualilications. f��,�,�,�:_� �_,,i, _,�l. �%
ame of applicant (owner o�
applicant the sole legal or
name on record is difteren
ame of contrad seller (apF
idress of contract seller
'<i gdistr ct � �
�
es ❑ No
mu5t pave been buVino On ContraCt at /east one
r / Leg�
_�
:�ffoperty Osed and occupied primarily for
er residence? �
�- es ❑ No
the applicant 65 years of age or more on December 37 of the year
to ihe current
)
d by a survivin9, unmarried spouse, what was the spouse's age at
me of death?
! you filed for any other deductions?
es ❑ No
! you filed for deductions in any oiher county?
It ownetl with sameone
indicate wiih whom
number
spouse,
Page number
0�.0 0 �
:essed value of ihe property as of March 1, current year (may no(
eed s2i,000)
❑ Yes ❑ No
�s the combined annual adjusted gross income of the appiicant and any
viduals sharing ownership exceed 520,000?
❑ Yes ❑ No
i Seuree of Ineome Amount of Income
I�
$
TOTAL $
❑ Yes �o I
I/We certify under penalty of perjury that the above and foregoing information is irue and correct and that the applican! was a resi-
dent of Indiana and owner ot the aforementioned property on March 1, 19 •
ture of licant Signature ol authorized represeniative (6y execu(ed Power olAttorney)
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