HomeMy WebLinkAboutAge_McEllhiney (3)nat AFFIDAVIT OF PERSON� 65 YEARS OF AGE OR MORE� COUNTY TOWNSHIP vEnR
::-- , 1; 'REQUESTING DEDUCTION FROM ASSESSED VALUATION
- � State Fortn 43708 (R3 / &00)
i���, Preuribed by ihe State Board otTaz Commissioners
�•• File Mark
I, nation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS FOR FILING: � �
To be �led in person or 6y mail with the County Auditor o/ the county whe� the property is 1 a- I�
ted during the 12 months be%re May 11 of the year the deduction is to be effective.
Deductions tor mobile homes not assessed as 2a1 property must file be(ween January 15 and F t g 2'7 Z00�
Mnmh Q I
See reverse side for additional instrucUon and quali(cations.
Name of applipnt (owner or contract buyer) / (31BSON C �
� -e � _ =1�,=�=�_ � � s r
Is applicani the sole legal or equitable own R If No, what is hisRier exad share or interest? If owned with someone other than spouse,
�� indicate with whom
L�3'Ye5 ❑ No d'"b —^
If name on record is different than that of applicant, indipte below
Name of contract seller (applicant must have been buying on contracf at leest one (1) yeer)
Address of contred seller
Tazing dis Key number / Legal description Record number Page number
.
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Is the eal property used and o upied Assessed value o( the property as of March 1, curtent year (may not
primariy �or hisRier residence? ezceed $69,000)
�Yes ❑ No
Was the applicant 65 years of age or more on December 37 of the year poes the combined annuai adjusted gross income ot the applicant and any
prior to ihe wrrent yeaR individuals sharing ownership exceed $25,0007
Yes ❑ No ❑ Yes ❑ No
P.pplicanYs date
Tca.�. �ZA,lz.,�w $ a 3 �.a c�
If filed by a surv'rving, unmarried spouse, what was the spouse's age at $ .
ihe time of death?
TOTAL $
Have ou filed f r any other deductions? If Yes, wha deductions?
�0 7-'�� es ❑ No Y/z-n--��`' �/'-w '
Have you filed for deductions in any other county? if Ye , what counry?
❑ Yes o
I/We certify 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 the aforementioned property on March 1, 20 _
Signature of appiicant Signature of authorized representative (by executed Power ofAttomey)
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�ess of applicant Address of authorized representative ,
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