HomeMy WebLinkAboutAge_Potters,i�'"o AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
i � REQUESTING DEDUCTION FROM ASSESSED VALUATION
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Stare Form 43708 (R / 9-96)
�"�• Prescribetl by the State Board of Tax Commissioners
Intormation coniained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS FOR FILING:
To be liled in peison or by mail wrth the County Auditoi ol the county where the property is loca-
ted during the 72 months before May 77 0! the year the deduction is to be eflective.
Deductions for mobile homes not assessed as real property must Iile beRVeen January 75 and
March 31.
See �everse side �or additional instruction and qualifications.
AUG 1 7 �ggg
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�-���ON OU� 7Y AUDITOR
Name of applicani (owner or conhact buye�)
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Is applicant the sole legal or equitable owner? If No, what is his/her exact share of interest? If owned with someone other than spouse,
indicate wiih whom
Yes ❑ No
If name on rewrd is different iha that of applicant, indicate below
Name of contract seller (applicant must have been buying on rontract at least one (1) year) -
Address of contract seiler
ing district Key number / Legal descripiion Record number Page number
� `.__ _
Is the property used and occupied primarily for — Assessedvalue of the property as of March 7, current year (maynot
hisfier residence? exceed 321.000)
❑ Yes ❑ No ❑ Yes
Was the applicant 65 years of age or more on December 31 of ihe year poes the combined annual adjusted gross income of the applicant and any
prior to the current year? individuals sharinq ownership exceed 520,000?
�`'� ❑ Yes o
Applicant'S date of
I �.s I $ ._
If filed by a surviving, unmarried spouse, what was the spouse's age at $
Ihe time of death? �
TOTAL $ �—
Have you filed for any oiher deductions? If Yes, what deductions?
�es ❑ No
Have you liled for deductions in any other county? � If Yes, what counry?
❑ Yes C� •
IlWe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
deN of Indiana and owner of ihe a(orementioned property on March 1, 19 -
SignaW re of applicant SignaNre ot auihorized representative (by executed Power o/A(/omey) {
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Add ss ot applicant A authorized representative
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