HomeMy WebLinkAboutAge_Loveless�,_R�• � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�� � State fortn 43708 (R614-Oa) �
• Presrnbe0 by iha DepartmeN of Local Gwemment Finance
Yltortnation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.7-35-9.
INSTRUCTIONS:
7o be filed in person or by mail with the Counry Auditor o/ the county where
the propeRy is located.
See reverse side for addifional instruction and qualifications.
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FILING DATES: O/(fQ ��
1) Real p��Y�. 6r�1��12�i%iii�{3 6efore May
11 of the year the deduction is to be eBective.
2) Mo6ile homes assessed under 1.C.6-1 •1-7;
behveen January 15 and Ma�ch 31 of the year
fhe deduction is to be eflecfive.
Name of applicant (owner or contracf buyerJ I
Is applicant the sole legal or equitable owne(? If No, what is hislher exad share or interest? If owned with someone other than spouse,
�,,G ' indirate with whom
,a� Yes � No
If name on recard is diRerent ihan ihat o( applicant. Indicate below �
Name of contrad se0er (applicant must have been buying on contrect at least one (7) year)
Address ot conVact seller Is tha property in question:
�(p-�� -/a -a.0/-p� �p58- �.a R alproperty ❑ Mobilehome(I.C.6-1-1-n
� g d' 'ct Key number / Legal description Record number Page number
0/ 9�%�58'- �
Is the property used an occupied primarily for Pssessed value of the property as of March 1, current year (may not
hisRier residence? exceed 5144,000)
Yes ❑ No
Was Ihe applicant 65 years of age or more on December 37 of fhe year poes fhe wmbined annual adjusted gross income ot the applicant and any
priw to the current yearl � individuats sharing ovmership exceed 525,0007
es ❑ No ❑ Yes
Appliwnt's date of birth (monfh, day, yearJ Soutce of Income Amoun of Income
was lha spouse's age at $
the fime of death?
TOTAL $
Have you filed for any other deductions? If Yes, whai deductlons?
❑ Yes ❑ No
Have you fled for deduc6ons in any oiher couniy? If Yes, what counry?
❑ Yes ❑ No
IMIe certiry under penalty of perjury that the above and foregoing informalion is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned propeRy on March 7, 20 _
Signature of appiicant I SignaNre of authorized representative (by execufed Power o7Attomey)
ress of applicant IAddress of authorized representative (
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