Age_HigginsX
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�° �_ n_• 1 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
" REQUESTING DEDUCTION FROM ASSESSED VALUATION
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Prescribed by the Departmen� ol Local Govemment Finance
�rma6on coniained in this document is CONFIDENTIAL pursuani to IC 6-1.�-12-9 and IC G7.7-359.
INSTRUCTIONS:
To be filed in person or 6y mail with the County Auditor o/ the county wirere
the propeRy is located.
See reverse side for additional insUuction and qualifications.
COUNTY TOWNSHIP YEAR
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File Mark
MAR 0 5 2007
FILING DATES:
1) Real property: Duringdhe 12,m�nths 6efore May
11 0/ the year the�e�fion is` o �e eKective.
2) Mo6ile horr�S}8d�esT@dlclr�dequQlB(1�-7;
behveen January 15 and March 31 of ti�e year
the deduction is to 6e e(/ective.
Name of applicant (owner or wntract 6uyer) "
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Is appliran e s le legal or equitable owner. If No, what is his/her exact share or interest? If owned with someone olher than spouse,
' indicate with whom
Yes ❑ No
If name on record is diRerent an that of applicant, indicate below
Name of contrad seller (appllcant musf have been buying on conUact at least ona (1J year)
Address of conVact seller Is the property in quesfion:
a�-� �-O(o - o�(_ 00,2.1-0 7•0�8 Real property ❑ Mobile home (I.C. 6-1•7•7)
Taxing ' trict Key number / Legal description Record number Page number
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Is the property used and occupied primarily for Assessed value of the property as of March 1, current year (may nof
hislher residence? exceed S 744, 000J
Yes ❑ No
Was ihe appliwnt 65 years of age or more on December 37 of the year poes the combined annual adjusted gross inwme of Ihe applicant and any
prior to the curtent year7 individuals sharing ovmership exceed 525,0007
Yes ❑ No . O Yes ❑ No
AppliwnYs year) Source of Income Amount of Income
/ �-� g
If filed by a surviving, unmarried spouse, what was ihe spouse's age at $
the Ume ot deaih�
TOTAL $
Have you filed for any oiher deductions? If Yes, what deductions?
Yes ❑ No � � ��
Have you filed for deducUons in any olher couniy? If Yes, wh county?
❑ Yes o �
I/We certify under penalty of perjury lhat lhe above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned propeRy on March 7, 20 _
Signature of applicant Signature ol authorized representative (by executed Power oJAttomey)
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ess of appliwnt Address of authorized representative
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