HomeMy WebLinkAboutAge_McIntire (3).° �4= AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
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' ,��� � State Fortn 43708 (R6 / 4-04)
Prescribed by Ne Departmem of Local Govemment Finance
InTormation contained in Ihis document is CONFIDENTIAL pursuant to IC 6-7.1-72-9 and IC 6-1.1-35-9.
INSTRUCTIONS:
To 6e �led in person o� 6y mail with the CountyAudito� o( the county where
the property is located.
See reverse side !or additional instruction and quali(cations.
COUNTY TOWNSHIP YEAR
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FILING DATESA:A p 'nn�
1) Real propett�'DuQn�ti�2'months be%re May
11 of the year the deduction is to be ef(ecfive.
2)Mobilehoines,assesse underl.C.61-1J;
i�ra�+ ��
beriveen J�nuaryJ75 and March 31 of the year
the �tln;Rflta'bbYe/i&�hiTe.�R
Name of appli t(owner or conVact buyer)
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Is appliwnt the e legal or equitable ovmer? If No, what is his/her exact share or interesl? If owned with someone other than spouse,
� indicate with whom
QYes ❑No
If name on record is diBerent ihan that of applicant, indicate below .
Name of contraa setler (applrcant must have been buying on contract at least one (i) year) •
Address of contract seller Is the property in question:
❑ Real property ❑ Mobile home (I.C. 6-1-1-7)
in ' trict Key number / Legal description Record number Page number
� - DOq(�S-OD
Is the properry used and occupied primarity for Assessed value of the property as of March 1, current year (may not
hismer residence? exceed 3744,000)
❑ Yes No
Was the applicant 65 years ot age or more on December 31 the year poes the combined annual adjusted gross income of the applicant and a
prior to the current year? individuals sharing ownership exceed $25,0007
es ❑ No ❑ Yes o
AppliwnPs date of birth (monfh, day, year) Sourc of Income Amount of Income
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was the spouse's age at $
the Gme of death?
TOTAL $
Have you filed for any other deductions? I( Yes, what deducdons?
❑ Yes ❑ No
Have you filed for deductlons in any olher county7 If Yes, what wunty? �
❑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 of the aforementioned property on March 1, 20 _
ignatur appliwnt Signature of authorized representative (by exetuted Power olAttomeyJ
r s applicant Address of authorized representative
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