HomeMy WebLinkAboutAge_Montgomery--�- ::
aj=�"v AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�` ` RE�UESTING DEDUCTION FROM ASSESSED VALUATION
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State Form <3708 (R / 9-96)
�f ' Prescnbed by ihe State Board of Tax Commissioners (,..�
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Information contained in this document is CONFIDENTIAL pursuani to IC 6-7.1-12-9. �
INSTRUCTIONS FOR FILING: � " �
To be liled in peison or by mail with the County Auditor ol the county where the p�operty is loca-
ted during the 72 months be/ore May 77 0/ the year the deduction is to be ellective.
Deductions !or mobile homes not assessed as real property must lile between January 75 and
March 31.
See reverse side lor additional instruction and qualitications.
COUNTY TOWNSHIP YEAR
� File Mark
Name of applirani (owner or confracf 6uye� �
ts applirant the sole legal or itable owner? If No, what is hisfier x ct share of inter t? If owned with someone oiher than spouse,
indicate with whom
�Yes ❑ No
If name on record is different ihLan that of applicani, indicate below
�l.C�.� � .
Name of contrac s Iler (applicant mu ave been buying on contract at least one (1) yeai)
Address of contract seller
�<ing di ict Key number / Legal descripiion Rewrd number Page number
U - - �d
is the property used and occupied rimarily for Assessed value of ihe property as of March 1, current year (may nof
his/her residence? exceed $21,000)
❑ Yes ❑ No ❑ Yes �No
Was the applicant 65 years of age or more on December 37 ot the year poes ihe combined annual adjusted gross income of Ihe applicant and any
prior to the current year? individuals sharing ownership exceed 520,000? ��
❑ Yes Ly'Na
Applicant'
$
If tiled by a surviving, unmarried spouse, what was the spouse's age at $
the time of death?
TOTAL $
Have you filed for any other deductions? It Yes. what deductions?
❑ Yes C�'�10
Have you filed for deductions in any o,her counry? If Yes, what counry?
❑Yes �JNo
I/We certify under penalty of perjury that the above and foregoing information is true and correct and ihat the applicant was a resi-
deni of Indiana and owner of the aforementioned property on March 1, 19 _
Signature of applicant Signature of authorized representative (by executed Power o7Attomey)
ess of applicant Address of authorized representative
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