HomeMy WebLinkAboutAge_Defelice- °` -"o AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
;a � RE�UESTING DEDUCTION FROM ASSESSED VALUATION
��' S�ate Form as7oe (R i 9-9e)
�`,�,—; �"• Prescribed by Ihe State Board ot Tae Commissioners
Information contained in ihis document is CONFIDENTIAL pursuant to IC 6-1.1-72-9.
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor ol the count}• where the property is loca-
ted during !he 12 months belore May 77 of the year the deduction is to be effective.
Deductions !or mobile homes not assessed as real property must lile beRveen January i5 and
March 37.
See reverse side !or additional instruction and qualilications.
COUNTY TOWNSHIP YEAR
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Name of applicant �owner or contract buyer/
Is applicant th o e Iegal or equita owner? If No, what is hisJher exact share of interest? If owned with someone other than spouse,
indirate wi[h whom
❑ Yes ❑ No
If name on record is diHerent Ihar1 thai of applicant, indicate below
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Name of contrad selkr (applicanf must have been buying om m�tract at least one (1) year)
Address of contract seller
u istrici Key number / Legal description Record number Page number
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Is the propeny used and occupied primarily for Assessed value of the property as of March 7, current year (maynot
hisfier residence? exceed 327,000)
Yes ❑ No ❑ Yes ��16
Was the applicani 65 years of age or more on December 37 of the year poes the combined annual adjusted gross income of the applicani and any
prior to the current year? individuals sharing ownership exceed 520,000?
❑ Yes �'No
Applicanfs date of birth (
spouse's age at $
the time of death?
TOTAL S
Have you tiled for any other deduciions? If Yes, what deductions?
❑ Yes CrtQo
Have you filed for deductions in any other county? If Yes, what couniy?
❑ Yes �
IlWe 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 _ . �
ISignawre of a i ant SignaWre of authorizetl representative (by executed Power olAttomey) 'I
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I, dress of p� m IAddress of authorized representative i