HomeMy WebLinkAboutAge_Davis (3)� rt•, • COUNTY TOWNSHIP YEAR
3__ � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
= REQUESTING DEDUCTION FROM ASSESSED VALUATION
� i State Fwm 43708 (Ra / 10-01)
� Prestnbed by Ihe Department of Local Govemment Finance
File Mark
�aUon wntained in this dowment is CONFIDENTIAL pursuant lo IC 6-1.7-12-9. }� _ .
INSTRUCTIONS: p FILINGDATLS:�� ~'
�.
To be filed in person or by mail wilh the County Auditor of the county where p 1) Real property: Dudng the 12 montF,s 6elore May
the property is located. � 11 of fhe year the ded �ction, is to be ef(ective.
��. 2) Mobile homes assessed un`der%C.6-1-1-7;
See reverse side /or additional instruction and qualifications. d between January 15 and Ma�ch 31 of the year
� the ded�ucfion is to be'effective.
i�"niacn ° n rr..-} '.�n���
Name of applicant (owne r on acf buyer)
� �;�
Is applicant the I legal or equitable mmer? If No, what is his/her exact share w interest? If ovmed vrith someone other than spouse,
indicate with whom
es ❑ No
If name on record is diflerent Ihan that of applicant, indicate below
Name of contract s er (applicant musf have been buying on contract at least one (1) yearJ
Address of w ad seller Is the property in question:
❑ Real pmperty ❑ Mobile home (I.Q 6-14-7)
Tabng di Key number / Legal desaiptlon Record number Page number
�b_-/9---�3:o.-a3 �o�
Is the property used and ocwpied primarily (or Assessed value of the property as o( March 1, wrrent year (may not
hisRier residence? exceed 569,000J
es ❑ No
Was the applicant 65 years of age or more on Dece ber 31 of the year poes the combined annual adjusted gross inwme of ihe applicant and any
prior to Ihe wrrent year? individuals sharing ownership exceed $25,000?
Yes ❑ No p Yes ❑ No
ApplinnYS date o( birth (month, day, year)
$
Have you filed (or any olher deductions? If Yes, what deducfions?
❑ Yes f�No
Have you filed for deductions in any other county? If Yes, what county?
❑ Yes o
INVe certify under penalty of perjury that ihe above and foregoing infortnation is irue and correct and that the applicant was a resi-
denl of Indiana and owner of lhe aforementioned property on March 1, 20 _
Signa[ure of applirant Signature of authorized representative (by executed Power olAttomey)
�� ,i / �
YV
ess of applicanl Address of aufhorized representative
3 a3,�--.�