HomeMy WebLinkAboutAge_Simms. R.,
° �� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, COUNTY TOWNSHIP venR
?� �. ° REQUESTING DEDUCTION FROM ASSESSED VALUATION
>��.° Sute Fortn 43708 (R6 / 4-04)
• Prescribed by ihe Depanment of Lowl Govemment Pinance
File Mark
ation wntained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1359.
INSTRUCTIONS: FILfNG DATES:
To be filed in person or by mail with the County Auditor o/ the county where
the propeRy is located.
See reverse side /o� additional instniction and qualifications.
1) Rea/ property: Dunng the 12 months befo2 May
f 1 0( the year the deduction is to 6e eHective.
2) Rt�mesasse'ss'etlunZT .C.E1-1-7;
be n ant�ary 15arid �ich 31 of the year
t ed�onae�b ��elfes°' .
Name of applicant (owner ontract buyer) � � .
' ` .
Is applicant the sole legal or uitabl o ef? If No, what is hislher exact share or interest? If ow ed with�4omeonEother than spouse,
��gJ���Y kUDITOR
Q Yes o
If name on record is diRerent fhan Nat of applicant, indicate below
Name of contract seller (ap licant must have 6een buying on contract at least one (f) year)
Address of wntract selle Is lhe property in questlon:
❑ Real property ❑ Mobile home (I.C. 6-1-1-7)
Ta�cing ''ct Key number / Legal descripiion Record number Page number
d Ig -odS98-oa
Ne prop rty used and ocwpied primariy for Assessed value of the property as of March 7, current year (may nof
hismer residence? exceed 8744,000)
Yes ❑No �d
Was the applicant 65 years of age or more on December 31 of the year poes ihe combined annual adjusted gross income o( the applipnt and any
prior to ihe curtent year? individuals sharing ownership exceed $25,0007
❑ Yes ❑ No ❑ Yes ❑ No
ApplicanPS date of birth (month, day, year) Source of Income Amount of Income
.
the spouse's age at � $
the time of death?
TOTAL $
Have you filed (or any other deduclions7 If Yes, what deducUons? _
❑ Yes ❑ No
Have you filed for dedudions in any other county? If Yes, what county?
❑ Yes ❑ No
INVe certify under penalty of pery'ury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
S' — f applicant � Signature of authorized representative (by executed Power ofAttomeyJ �
� � �
� -
� of appl' nt Address of authorized represenWtive
o � - - �-,� -