HomeMy WebLinkAboutAge_McCrary3Rryn � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
' REQUESTING DEDUCTION FROM ASSESSED VALUATION
t�N � Suta Fortn 43708 (R4 / 10.01)
Pres�ribed by Ne Depanment of Local Govemment Finance
In(ortnalion contained in this dowment is CONFIDENTIAL pursuant to IC 6-1.1-72-9.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of fhe county where
fhe property is located.
See reverse side Ior addRional instruction and qualifications.
or
Is applipnt the sole Iegai or
hisRier exact shz�e or interest?
.tSYes ❑ No I
If name on rewrd is different than ihat of applicant, indicate below
Name of contrad seller (appliwnt musf have been buying on contract af least one
conVad
.
Is the propertyused and occupied primarily for
hisRier residence?
�s ❑No
Was the appiicant 65 years of age or more on December 31 of the year
prior to the current yea�?
0�les�O No
ApplicanPs
what was the spouse's age at
the time ot death7
you uiea �or any
you filed for deduc6ons in any olher county?
❑ Yes ❑ No
O Yes ❑ No
COUNTY TOWNSHIP YEAR
File Mark
FILING DATES:
t'�
1) Real property unn th 12 maMh,s b/ore May
11 of the year the de u s-�he e ec e.
2J Mobile homes �sg�g¢� u,nde�BC�6�-1-1- �
between Janua �3'�r�d A-1�}c f Ihe ear
the deduction is to be effective.
owned with someone
dicate vrith whom
Is lhe property in question:
❑ Real property ❑ Mobile home (I.Q fr1J-n
Record number Paqe number
�J
of �}le DfOD01jV a5
year
combined annual adjusted gross income o( the applicant and any
s shanng ownership exceed $25,000?
Source of Income
� ,
�
i
Yes, what deducli s?
Yes, what county?
❑ Yes ❑ No
Amount of Income
$ �/ 4'S.
$ go .
TOTAL I $
Y❑
I/We certify under penalty of perjury tha� the above and foregoing infortnation is irue and correct and lhal the applicant was a resi-
dent of Indiana and owner of lhe aforementioned property on March 1, 20 _ .
ature of applicant Signature of aulhorized representative (by executed Powei olAttomeyJ
of app4pnt
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