Age_Ray.� R.�•
AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
`= REQUESTING DEDUCTION FROM ASSESSED VALUATION
��H i su�e Form a3�oe (RO � to-ot)
Prescribed by the Department of Local Govemment Finance
�rtnalion conlained in lhis dowment is CONFIDENTIAL pursuant to IC 6-1.7-12-9.
INSTRUCTIONS:
To be filed in person or by mail wifh the County Auditor of the county where
the property is /ocated.
See reverse side for additional instruction and qualifications.
COUNTY � TOWNSHIP � YEAR
FILING DAY�S: U '(�(�
1) Real prope�ty: �r Hg t�e41 �rM2S�F,s before May
11 0/ the year the deductio s to be ffe ive.
2) Mo6ile h mes assess d er I.0 1- 7;
befween � a f3t'�t e year
thede, t�rr�'tb:6e�i}���C�e.�'��
Name ot applicant (owner or conhact bvyer)
� �� I
Is applicant ihe sole tegal or equitable owner? If No, t is hisAier exact share interest? If owned wiih someone other ihan spouse,
indicate with whom
❑ Yes ❑ No
If name on record is diRerent than ihal of applicant, indicate beiow
Name of contrad seller (applicant must bave been buying on contract at least one (i) year)
Address of wntrad seller . Is lhe property in question:
❑ Real property ❑ Mobile home (I.C. 6-14-�
��T bn districl Key number I Legal description Record number Page number
=0D �!- -5_�a
Is the property used and occupied primarily for � {�ssessed value o( the property as of March 7, cuvent year (may not
hisRier residence? exceed 569, 000)
es ❑ No
Was the applicant 65 years of age or more on December 37 o e year poes the combined annual adjusted gross income of the applica d any
prior to the curreN year? individuals sharing ownership exceed 525,000?
es ❑ No es ❑ No
ApplicanPs
$
Have you filed for any olher deduc6ons? If Yes, what deducGons?
❑Yes ❑No
Have you filed for deductions in any ofher county? If Yes, what county?
❑ Yes ❑ No
IIWe ceRify under penalty of perjury that the above and foregoing information is true and correcl and lhat the applicant was a resi-
denl of Indiana and owner of lhe aforementioned property on March 1, 20 _
' nature of applicant Signature of authorized representative (by executed Power ofAttomey)
�ress o ppiicant ( Address of authorized representative
iO3
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