HomeMy WebLinkAboutAge_Lacy� R.,
3 � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
� REQUESTING DEDUCTION FROM ASSESSED VALUATION
� �N � State Fo�m 43708 (R4 / 10-07 ) A
Prescnbed by Ne Department of Local Govemment Finance / �
V
In ormalion contained in ihis dowmenl is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS:
To be filed in person or by mail wifh the County Auditor o/ the county where
the p�operty is /ocated.
COUNTY TOWNSHIP YEAR
File Mark
FILING DATES��
1) � Dunn th 1 nths befo2 May
11 e ar de uction is to be eHective.
2) Mo 7e homes a�ce�ss��'�ide�1.C.G1-1-7;
See reverse side for additional instn�ction and qualifications. befween J��r3C1 Salfd March 31 the year
the deduc(i �on is fo 6e elfecfive
� �
Nameofapplicant nerorcont2ctbuyerJ I/ ,T� q�Q1` �
� � — - - — — — — -9cnPlC�V�
>
Is applicanl the sole legal or equitable wner? If No, whal is is/her exact share or interest? f owned ' om one olher than spouse,
indicate w' om
❑ Yes ❑ No
If name on record is diflerent than lhat oi applipnt, indicate below
Name of contracl seller (applicanf must have been buying on confract af least one (1) year)
Address of wntraG seller Is the property in question:
❑ Real property ❑ Mobile home (I.C. 67-7-7)
T ring ' trict Key number / Legal description Record number Page number '
�
(�'� ------ — --
Is ihe property used and ocwpied primarity for — Assessed value o( the property as of March 7, wrrent year (may noi
hisRier residence? exceed 869,000)
tyres ❑ No
Was the applinnt 65 years of age or more on December 31 of the year poes the combined annual adjusted gross inwme of the applicant and any
prior to ihe wrrent year? indi�riduals sharing ownership exceed 525,000?
es ❑ No ❑ Yes ❑ No
ApplicanPs date of birth (month, day, year) � Source of Income Amount of Income
.� � � $
If filed by a surviving, unmarried spouse, what was the spouse's a9e at �y
the fime of death?
TOTAL $
Have you filed for any other deductions? If Yes, what deduc6ons?
❑ Yes �'fJo
Have you filed for deductions in any other county? If Yes, what county?
❑ Yes C'yt�o
IIWe certity under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of lhe aforementioned propeAy on March t, 20 _
Sign ure of applifant Signature of authorized represenlative (by executed Power of.".ttomey)
2,�L...��- Z° .
.ress oi applicant Address of aulhorized representative