HomeMy WebLinkAboutAge_Engler• ^•n
� � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courm TOWNSHIP veart
�r� � REQUESTING DEDUCTION FROM ASSESSED VALUATION
S � State Fortn 43708 (R6 / 4-04)
Prescribed by lhe Depariment of Lowl Govemment Finance
File Mark
natlon contained in this document is CONFIDENTIAL pursuant to IC 6-1.7-72-9 and IC 6-1.1359.
INSTRUCTfONS:
7o be �led in person o� 6y mai! with the County Auditor of the county where
the property is located.
FILING Os�E : I � � �
1) Real property: Dunng the 12 monfhs be(ore May
11 of the year �l�,�e�ugtio��o 6e ef(ective.
2) Mobile homes a's�3essed u`nder 1.C.6-1-1-7;
See reverse side fo� additional instruction and qualifications. 6etween January 15 and March 31 of the year
the deductio �S,ta(t� s8'a�r�i�.
�J� U
Nameofappli nt wnerprcontracf�) ^ - G
li(1► 1/I I�
��a �C'c U'�-:
Is applicant the wle legal or equitable ovme� If No, wha his/her exact share or interest? If owned with someone other than spouse,
' indicate with whom
�'es ❑ No
If name on record is different than that of applicant, indicate below
Name of contract se er (applicant must have been buying on cont2ct at least one (1 f year)
�
Address of conVact eller Is lhe property in quesUon:
❑ Real property ❑ Mobile home (I.C. 67-1-n
Taxin i"ct Key number / Legal descriptlon Record number Page number
�� s-Ob%S� -�c
1 ine property used and occupied primarity for Assessed value of the property as of March 1, current year (may nof
hismer residence? exceed 3144,000)
C�.'es ❑ No
Was the applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the wrtent year? individuals sharing ovmership exceed $25,000? �
❑ Yes ❑ No ❑ Yes ❑ No .
ApplicanPs date of birth (
$
Have you filed for any olher deductions? If Yes, what deducUons?
b Yes o
Have you filed tor deductions in any other county? If Yes, what wunt�!� ,
❑ Yes o
I/We certify under penalty of perjury ihat the above and foregoing information is true and correct and thal the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
Signature of applicant Signature of authorized representative (by executed Power o)AttomeyJ
`ess ��p� n�t/�� A� �, ���p - Address of authorized representative
(/� ..C�C�I /C� "" " � ,