HomeMy WebLinkAboutAge_Lamar° rt n�� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MOR couNTV TOWNSHIP veaR
REQUESTING DEDUCTION FROM ASSESSED VALUA
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'��+��` State Fortn 43708 (R6 / 4-Oa) �
Prescribed by tha Department ol Local Govemment Financa
I�rmatlon contained in this document is CONFIDENTIAL pursuant lo IC 6-1.7-12-9 and IC 6-1.13S�QY 5 2005 File Ma�k
INSTRUCTIONS: 9 FI G DATES:
To be filed in person or by mail with the County Auditor of the county where ILJ�y1 � nng the 12 months 6efore May
the property is /ocated. ��GIBS @f��l$�ction is to 6e eHective.
2�Mobde homes assessed under I.C.6-1-1-7;
See reverse side (or addilional insUuction and qualifications. � behveen January 15 and March 31 of the year
�� the deduction is to 6e ef/ective.
Name of applicant (owner or contract buyer) �
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Is applicant the sol gal or equitable owner? If No, what' ' er exact share or interest? If owned with someone other than spouse,
—� indicate with whom
Q Yes ❑ No �
I( name on record is diRerent ihan that o( applicant, indicate below
Name of contract seller (applicant must have been buying on contract at least one (1) year) .
Address of wntrad seller Is the property in question:
❑ Real property ❑ Mobile home (I.C. 6-1-1-n
' g istrict Key number / Legal description � Rewrd number Page number
— lS3°� —D
Is property used and occupied primarily for Assessed value o( Ne property as of March 1, current year (may not
hisRier residence? exceed 3144,000)
❑ Yes ❑ No
Was Ne appliwnt 65 years of age or more on December 31 f the year poes the wmbined annual adjusted gross income of the applicant and any
prior to the cunent year? individuals sharing ovmership exceed $25,0007
es ❑ No ❑ Yes ❑ No
AppliwnPS da[e
spouse's age at $ —
ihe time of death? �
TOTAL $
Have you filed for any other deduclions? I( Yes, what deducfions? .
❑ Yes ❑ No
Have you filed for deductions in any other county? If Yes, what county?
❑Yes ❑No
IPNe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March t, 20 _
Signa ure o pplicant Signature of authorized representative (by ezecuted Power olAttomey)
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s of applicant , Address of authorized represenWtive
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