HomeMy WebLinkAboutAge_Hart (3)_� , 4 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
° ° REQUESTING DEDUCTION FROM ASSESSED VALUATION
�O � State Fortn 63708 (R6 / 4-04) ' �
•• Prescnbed by Uie Depariment af Lowl Govemment Finance
�rmaGon contained in lhis document is CONFIDENTIAL pursuant to IC 6•7.1•12-9 and IC 6-1.1•359.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o/ the county where
the property is located.
See �everse side !o� additional instruction and qualifications.
TOWNSHIP YEAR
I � � .�
JUN Oe7 ���`06
FILING DATES:
1) Real property: Dur'�'the�12'�s before May
,11 0/ the year the desd�u��4�,�$ �p pe�{(�ctive.
2 Mo6ile horr%���e l7ndeF1.�'s=�=i-r,
behveen January 15 and March 31 o/the yea�
the deduction is to be e/%ctive.
Name of ap lirant (owner or contrect buyerJ �
Is ap i nt e sole legal or equita e owneR I( No, what is hislher exact share or interest? If owned with someone other than spouse,
' indicate with whom
O Yes ❑ No
II name on rewrd is different than ihat o( applicant, indiCate below .
Name of contract seUer (applicant must have 6een buying on contract atleast one (7) year)
Address o( convact seller Is the property in question:
- Real property ❑ Mobile home (I.C. 6-1-1-7)
T�strict, Key number / Legal description Record number Page number
�/ 9 �/O�(�r CTI�
Is the property used and occupied primarity for Assessed value of the property as of March 7, wrtent year (may not
his/her residence? exceed $144,000J
❑ Yes ❑ No
Was the appliwnt 65 years ot age or more on December 37 of the year poes the combined annual adjusted gross income of the applicant and any
pria to the wrrent year7 individuats sharing ownership exceed 525,0001
❑ Yes ❑ No ❑ Yes O No
AppliranCs date of birth (month, day, yearJ
❑ Yes ❑ No
i/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 7, 20 _
Signature of applicant Signature ol authorized representative (by executed Power olAttomey)
.x� � �/-�-�"
�ess of applicant Address of aulhorized representative
�X �o� � ��",� ,�� �