HomeMy WebLinkAboutAge_JohnsAFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNTV TOWNSHIP r�
REQUESTING DEDUCTION FROM ASSESSED VALUATION
°• � � State Farm 43708 (R7 / 5-OB)
�' Prewibed by the Departrnen[ of Loral Govemment Finar�ce
Infortnation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-�.1-35-9. �� �le M� �
INSTRUCTIONS: FILING DATE
To be (led in person or by mail with the Counry Audiior of the county where 1) Real property: During the 12 months before �une
the properfy is located. 77 0( the yea� lhe ��uct�r�is�?g�� e(lective.
2J Mobile homes assessed under I.C.6-1-1-7;
See reverse side for additional instruction and qualifications. between January�d Magfj�21 o/ the year
the deduction is t �f�'a.�ln:6�
C'1....... U
GIBSON COUNTY At1DITOR
contrad 6uyer) �
Is appliqnt iBe sole legal or
❑Yes ❑No
name on record is diffefent Nan that of applican
musf have been
n,��vo�int ,
ie property used and ocwpied primarily for
ier residence?
: the apdicant 65 years of age w mwe on
r to the wrrent year?
dicanYs date
ed by a survmng, unmarried spouse, what
tlme of death?
�e you fiied for any other deductions?
re you filed for deductions in any other coui
If No, whatJ$ hisRier exact share w Int
U
idicate below
uying on contract at least one (i) year)
�es ❑No
ber.-3'I of the year
[�'es ❑No
was ihe spouse's age at
�s ❑No
exceed
owned vrith someone other Nan spouse,
dicate with whom
Is �he property in queslion: -
y�.�eal property Q Mobile home (I.C. 6-1-7-7j
Remrd numDer Page number
as ot March 7, current year
Does the combined annual adjusted gross income o( the applicant anA any
individuals sharing ownership exceed 525,000?
� ❑Yes ❑No
It
Source of Income Amount of Income
$
$
TOTAL $ �� OO � .-_-.��-
Yes, what deductions?
!-�. �' -r- irrr�.
oY� �.r�o �
I/We certify under penalty of perjury that the above and foregoing info�**+�t��n is true and correcl and that the applicant was a resident
of Indiana and owner of the atorementioned property on March 1, 20 _
..,�.� �.e .,r �...a;.y..� SionaW re of authorized representative (by executed Powei ofAttomey)
applinnt