HomeMy WebLinkAboutAge_Pollockm
AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S � Sfete Fortn 43708 (RS / 6-03)
Pfesai6ed �y the Departmeni of Loral Gavemment Finance
(
I�ortnation contained in this document is CONFIDENTIAI pursuant to IC 61.7-12-9.
COUNTY TOWNSHIP YEAR
File Mark
�RUCTIONS: FILING �� ,E5�M � �thy
To 6e Filed in person or by mail with the County Auditor o/ the county where 1) Re�pe@y:_Du1ng theJ2 on �s bafore May
the property is located. 11 of the year the deduction i�e etfective
See reverse side /or additional instruction and qualifications.
or
�1 Yes ❑ No I
name on record is ditferent Nan that of applicant, indicate below
used
or
must have 6een buying on contract at least one (1) }rear)
the applicant 65 years of age or more on
ro [he curtent year?
Have you filed for any other
you fled for deductions in any other
�Yes ❑ No
December 31 of the year
❑ Yes ❑ No
was ihe spouse's age at
Yes o
,ty?
❑Yes ❑No
2)Mobileh�e�assdss�A(}!�der1.C.6-1-1-7;
betrveen January 15 andtifaroh 31 0/ the year
1' AUDI70R
I with someane
wiN whom
the property in question:
spouse,
❑ Real property ❑ Mobile home (I.C. 6-7-1-7)
1tl value of Ne property a5 of MarCh 7, c
$144,000)
e combined annual adjusted gross incor
als sharing ownership exceed 525,000?
So te o Ineome
! � v .�(�n
deducUons?
me s-�ac{
uvent year (may nol
ne oi the applicant and any
l�es ❑ No
Amount of Income
�3
$
TOTAL � $ �
IIWe certify under penalty of perjury that the above and foregoing information is true and correcl and that the applicant was a resident
of Indiana and owner of the aforementioned propeRy on March 1, 20 _.
Signature of appliwnt � _ Signature of authorized representative (by executed Power o/Attomey)
Address of auNorized