HomeMy WebLinkAboutAge_Hughes`"' rt�na
S_ � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNrr TOWNSHIP vena
` REQUESTING DEDUCTION FROM ASSESSED VALUATION
� �ti � State Form 43708 (R4/10-07)
Prescnbed by Ihe DepartmeN ot Local Govemment Finance
File Mark
Intortnalion contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where
the property is located.
See reverse side Ior additional instruction and qualifications.
applicant the sole
name on
ier or pqnlracf buyer)
�Y' >
ial or eauilable ownei
es ❑ No I
�han �hat of applicant, indicate beiow
of contract seller
conVact
/
property used and occupied primarily for
r residence?
the app�icant 65 years of age or more on
to the wrrent year?
share
on contract at leasf one
tr� ❑ No
:mber 31 of ihe year
es ❑ No
tlicanCS date
ed by a surviving, unmartied spouse, what was Ihe spouse's age at
tlme of death?
you filed for any
you
any ofher county?
Cg'�es ❑ No
❑ Yes
FILING DATE� � � � �
�)1R1 o/the yeart�e��sbu,�i���e eNecti eay
2J Mo6ile h es assessed under I.C.6-1-1-7;
the ded anua� 1�S��n��V� 3��fthQ year
��
Assessed value of the
exceed 569, 000)
GIBSON �` � ' V
O(,N i v
If owned with someone other lhan spouse,
indicate with whom
property
❑ Real property ❑ Mobile home (I.C. 6-14-�
Record number Page number
as ot March 1, cuvent year
Does the�com6ined annual adjusted gross income of the appliwnf and any
individuals sharing ownership exceed $25,000?
Source of Income
�
�
TOTAL $
dedudions?
(
�¢�L�
county?
❑ Yes ❑ No
Amount of Income
IIWe certify under penalty of perjury that ihe above and foregoing informalion is true and correct and lhat the applicanl was a resi-
denl of Indiana and owner of the aforementioned propeAy on March 1, 20 _
�s of applicanl (/
: R. (�+�3
�76 70
of authorized representative (by executed Power o/AttomeyJ
of authorized representative