Age_McReynolds�,. ' .
� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cour+rr TOWNSHIP v�aa
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�' �w > State Farm 43708 (R7 / S-O6)
Preunbed by tlie Department of Laal Gwemmeni Fnance
�mation contained in this document is CONFIDENTIAL oursuant to IC 6-1.1-12-9 and IC 6-1.135-9. ���M �!+'zi
!
INSTRUCTIONS: FILING DATES:
To be filed in person or by mail with the CountyAuditor of the county where i) Real property: Durp��e�j2�o�(�s�before �une
the property is located. 11 of tbe year the de ct�fSn s�d� B' effective.
2) Mobi/e homes assessed under I.C.6-1-1-7;
See reverse side for additional instruction and qualifications. 6etween January J�13dM,3&'�J of the year
the deductio s lo be e�ective. �
�aI�SON COUNTY AU��?CR
Name o/j�,applicant (ovmeror contrad buyer) � /n/ ��
/ / � / /% � _ � e` U,✓ / �% .
applicant the sole legal or
❑Yes ❑No
name on reco�d is ditferent than that of applicart
�,^_7ii�TJ
Address of contract
what is hisAier exact share a
6een buying on contract af
�03 l% �
roperty used and ocwpied primarily for
residence?
'as ihe appiicant 65 years of age w more on December�37 of ihe year
ia ro the artent year? .
�Yes ❑No
�plipnYs date of birth (
�
filed by a surviving, unmarried spouse, whai was the spouse's age at
e tirtre of death? .
Have you filed for any
❑Yes �No
you filed for deductions in any
If owned witli someone other than spouse,
indirate with whom
- Is Ne pmperty in quesUOn: - -
Real property Q Mobile home (I.C. Gi-1-n
�/ /� Record number Page number
If Yes, what
ihe property as of
Source of Inwme
$25,000?
$
$
TOTAL $
year
arrt and any
❑No
d Income
i_
❑Yes ❑No I
UWe certify under penalty of perjury that the above and foregoing info•+*+�}��n is true and correct and thal the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
�naWre of applicant Signature of authorized represenia4ve (by executed Powe� ofAttomey)
applicant
of