HomeMy WebLinkAboutAge_Pyle (3). ^•n
`� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MpRE,
�r �` '� REQUESTING DEDUCTION FROM ASSESSED V/'" T'ON
�+ .° SWte Form 43708 (R6 / 4-0a) .
Prescribed by Ne Depariment of Local Govemment Finance
Information contained in this document is CONFIDENTIAL pursuant to' � , 6�f.13S9.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor
the property is located.
:
See reverse side tor addifional instniction and quali�ar'
` � :ING DATES: " 1�,(�
�er�+ Real property: During the 12-�yn�hs�e�r�e May
, 11 `f fhe year the deduction is to be eHective.
� 2) Mo' homes assessed under I.C.6�
b lanuary 15 and March ot th
R
� • . an is to be eHect4ve...-,��NTY A���
.,,.
� :�,:...
Name of applicant (owner o� conVact buye�J r_ � �
� O� � �
Is applicant the so ,�cgal or equitable ovmer I( No, what is his/her e ct share or interest? If owned with someone other than spouse,
� indicate with whom
Q Yes ❑ No
If name on record is difierent than that of applicant, indicate below
,� .
Name o( rnntrect seiler (applicant must have been buying on conf2ct at least one (1J year) � '
Address of conVact seller Is the property in questlon:
eal property ❑ Mobile home (I.C. 6-i-1-�
� dis ' �- Key number I Legal descripiion Record number Page number
� -Qa �_ 3 �
is the property used and occupied primarily (or Assessed value of the property as o( March 7, current year (may not
hisRier residence? exceed $144, 000)
� No
Was the applirant 65 years oF age or more on Dec mber 31 of ihe year poes the wmbined annual adjusted gross income of Ne applicant and any
prior to the curtent year? individuals sharing ovmership exceed $25,000?
. es ❑ No ❑ Yes ❑ No
AppliwnCs date of birth (month,
at $
the time of death? �
TOTAL $
Have you filed for any other deductions? If Yes, what deductions?
❑ Yes ❑ No
Have you filed for deducfions in any other counry? If Yes, what counry?
❑ Yes ❑ No
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that lhe applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant Signature of authorized representative (by executed Power olAttomey)
�of applicani Address of authorized represenlative