HomeMy WebLinkAboutAge_Ellis (3).; o_� • 4 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
' " REQUESTING DEDUCTION FROM ASSESSED VALUATION
S .� State Fortn 43708 (R6 / 4-04j �
PresrnDed by Ne Departmeni of Lowl Govemment Financa
�rmation wntained in this document is CONFIDENTIAL pursuant to IC 6•1.1-12-9 and IC 6-1.1359.
INSTRUCTIONS:
To 6e filed in person or 6y mail with the County Auditor ol the county where
the propeRy is located.
See �everse side for additional instruction and qualifrcations.
COUNTY TOWNSHIP YEAR
F a
FILING DATES: ��
1) Real properfy:'Tiunngrthe 1���onths before May
1 f of the year the deduction is to be elfective.
2) Mobile homes�,g,sSe� I.C.6-1-1-7;
between January 1�%nd M ch 31 0l the year
the dedEd�P/� %��L�cA�%�ITOR
Name of applicant (owner or contracf buyer) �/ _' .
a.e-m,i� K
Is applicant the sole legal or equitable o e� If No, what is his�her exact share or interest7 If owned with someone other than spouse,
indicate with whom
es ❑ No
If name on record is difierent than that of applicanl, indicate below
Name of contract seller (applicent musf have been buying on contract at least one (7) year)
Address of convad seller Is the property in question:
❑ Real property ❑ Mobile home (I.C. 6•1-7-7)
T'ng district Key number / Legal desaiption Rewrd number Page number
- I - - D - c'� � .��s-oa $
Is the property used and occupied primarity for Assessed value of the property as o( March 1, current year (may not
hisRier residence? exceed $144,000)
es ❑ No
Was the applicant 65 years of age or more on December 37 of fhe year poes fhe wmbined annual adjusted gross income of the appiiwnt and any
prior to the wrrent year? / individuals sharing ownership exceed 525,0007
L/Yi'es ❑ No ❑ Yes ❑ No
ApplicanPs date
ss g^
if filed by a surviving, unmartied spouse, what was the spouse's age at e�
the time of death?
TOTAL $
Have you filed for any other deductions? If Yes, whai deductions?
❑ Yes ❑ No
Have you filed for deducUons in any other wunty7 It Yes, what counry9 I
❑ Yes O No
I/We cert' under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident ` I
of Ind' a and owner of the aforementioned property on March 1, 20
' n ure of appliwnt Signature ot authorized representative (by execufed Power o7Attomey)
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d'A..A. 7N"'�' .
res of a plicant qddress of aulhorized representative
D4 � �b�a