HomeMy WebLinkAboutAge_Johns (5)��•"•°o AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
•° Y� REQUESTING DEDUCTION FROM ASSESSED County Township Year
;� VALUATION State Form 43708 (1-90) Prescribed by the
° State Board of Tax Commissioners ��
�
Instructions for filing: File Mark
To be filed in person or by mail with the County Auditor of the County where �( �ggg
property is located during the 12 months before May 11 of the year the eduction
is to be effective. Deductions for mobile homes not assessed as re��� %%�
mustfilebetween January 15 and March 31. See reverseforadditional ins ructio�DITORa�
and qualifications.
Applicant (Owner or cont� y,�r)
Co
Is applicant the sole legal or If , what is his/her exact share or If owned with someone other than
equitable owner? O yes ❑ no interest? spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
Name of contract seller (Appiicant must have been buying on contract at least one (1) year.)
Address of contract seller
District Key Number/Legal Descri tion Record No.
— —QC� Page No.
Is the real property used a occupied primarily Assessed value of the property as of March 1, current
for his/her residence? yes ❑ no year (may not exceed $19,000).,� )�
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Was th pplicant 65 years of age or more on ApplicanYs date of birth _ _
Dece ber 31 of the year prior to the current year?
yes ❑ no If filed by a surviving, unmarried spouse, what was the
spouse's age at the time of death?
Does the combined annual adjusted gross Source of income Amount of income
income of the app cant and any individuals �--�_,
sharing owner ip exceed $15,000?
❑ yes o
Total
Have you filed for any other deductions? If yes, what deductions?
Have you filed for any deductions in any other county? If yes, what county?
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
cant was a resident of Indiana and owner of the aforementioned property on March 1, 19
Signature Authorized Representative (by executed Power of Attorney)
� �,
Address of Applicant Address of Representative
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