HomeMy WebLinkAboutAge_Lee (5)d � � • COUNTY TOWNSHIP YEAR�
� 1 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
" REQUESTING DEDUCTION FROM ASSESSED VALUATION
�� �:� � State Fortn 43708 (R6 / 4-04) � . I �? �
• Presaibed by Ihe Department of Local Govemment Finance
. rmation coniained in this documeni is CONFIDENTIAL pursuant to IC 6•1.1-12-9 and IC 6-1.1-359.
i e l�lar
JUN 0 8 20W
INSTRUCTIONS: FILING DATES:
To be filed in person or by mail with the County Auditor of the county where
the property is located.
See reverse side !or additional instruction and qualifications.
1) Real property: Da �'9,the 12� onths belore May
11 0/ the year the�d" A'is�fojbe elfective.
2) Mobile hor�y�s�e�YiS�e��7LEr� � �-�:
befween January 15 and March 31 of the year
the deduction is to be eNective.
Name of applicanl (owner o� contrect buye�) ' I
Is applirant the wle legal o qui wne� If No, what is hislher exact share or inlerest? If owned with wmeone other than spouse,
, Indicate w(N whom
� Yes ❑ No
I( name on rewrd is diRerent fhan that of applicanC indicate below �
Name of contreIX se0er (applicant musf have been buying on conVact af least one (1) yearJ
Address of contract seller Is the property in question:
�Real property 0 Mobfle home (/.C. 6-14-7)
Taxing ' trict Key number / Legal description Rewrd number Page number
� � o��/�a�oa�
Is the property used and occupied primarily for Assessed value of the property as of March 1, current year (may not
hislher residence? exceed 5744,000)
❑Yes ❑No
Was the appliwnt 65 years of age or more on December 81 of the year poes the combined annual adjusted gross income of the applicant and any
pnor to the wrrent year7 individuals sharing ownership exceed 525,0007
es ❑ No ❑ Yes � No
Applicant'
Have you filed for any other deductions? If Yes, whal deductions7
❑ Yes ❑ No
Have you �led for deductions in any olher county? If Yes, what counry?
❑ Yes ❑ No
I/We 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 o( the aforementioned properfy on March 1, 20 _
� Signature of appliwnt I Signature of authorized representative (by execufed Power ofAttomey)
ress of ap- wnt � ; IAddress of authorized representative I
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