HomeMy WebLinkAboutAge_Greenwell3�.n t, AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�' ' REQUESTING DEDUCTION FROM ASSESSED VALUATION
` ..» ! Slate Form 43708 (R4 / 16-01)
Pres(sibeA by Ne Department of Local Gwemmem Finance
�malion contained in this document is CONFIDENTIAL pursuant to IC 6-1.7-12-9.
INSTRUCTIONS:
To be (led in person o� by mail with the County Auditor of the county whe�e
the property is located.
See reverse side foradditional instruction and qualifications.
COUNTY TOWNSHIP YEAR
�
M�� �aI'` 2002
FILING DATESnr"'"""'y""°�1` r���a
1J Real prope Zrrre y
11 o/the yeaithe"ii&�('io�rA3�Id"lic�ef(eaHve.
2) Mo6ile homes assessed underl.C.6-1-1-7;
between January 15 and March 31 of the year
the deduction is to be effective.
Name of applicant (owner or contract b er)
___ " ' __ — — �
Is applicant �he sole legal or quitable owner? If No, what is hisAier exact s ar r nteres . If owned wiih someone olher lhan spouse,
indicate with whom
❑ Yes ❑ No
If name on record is diHerent than ihat of applicant, indicate below
Name of contred seller (applicant must have been buying on contract at least one (7) year)
Address o( contraG seller Is the property in question:
❑ Real pmperty ❑ Mobile home Q.C. 64J-�
T' district Key number / Legal description Record number Page number
J �- --'— ' — - _ { �
Is ihe property used and occupied primarily for Assessed value of the properry as of March 1, current year (may nof
hismer residence? exceed 569,000)
es ❑ No
Was the applicant 65 years of age or more on December 31 of the year Dces the combined annual adjusted gross income of the applicant and any
prior to Ihe artent year? �� individuals sharing ovmership exceed 525,000?
LM'Yes ❑ No ❑ Yes t.yrao
P.pplicanYs date of birth (month, day, Source of Income Amount of Income
. � � $
If (tled by a surviving, unmarried spouse, what was lhe spouse's age al $
Ihe Ume of death?
TOTAL $ Q 3 5 S
Have you filed tor any olher deductlons? If Yes, what deduclions?
❑ Yes LWNo
Have you filed for deductions in any other county? If Yes, what wunty?
❑ Yes LVNo
IIVJe certify under penalty of perjury that the above and foregoing information is true and correct and that lhe applicant was a resi-
dent of Indiana and owner of lhe aforementioned property on March 1, 20 _
Sign ure of applicant Signature of authorized representative (by executed Power o(Affomey)
ess of applicant Address of auihorized representative
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