HomeMy WebLinkAboutAge_Slavik3__�•* 4 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
° REQUESTING DEDUCTION FROM ASSESSED VALUATION
t �� State Fam 43708 (Ra / 1P-01)
� •• Prescnbed by the Department ot local Govemmenl Finance
�rtnalion wntained in this document is CONFIDENTIAL pursuant lo IC 6-1.1-12-9.
INSTRUCTIONS:
To 6e filed in person or by mail wifh the CountyAuditoro/the county where
the property is /ocated.
See reverse srde for additional insfruction and qualifications.
ame of appl� nt (owner or contract buyer)
• �. !
applicant sole legal or equitable �' If
��
❑Yes ❑No
name on rewrd is difterenl Uian �hat of aoolicanl. inc
n
of contracl selier
and
below
exact share or interest?
must have been buying on tontract af least one (
a� �-03
Key number / Legal desuiptior
� Yes ❑ No
the applicant 65 years of age or more on December 31 of the year
to ihe wrtent yeaR /
q� O No
was
COUNTY I TOWNSHIP
���
YEAR
FILING D S:
1) Real propeAy�n�f1� ��tY,s befo2 May
11 0! the year the deductio is to be eflecfive.
2) Mo6ile es asses ed derl.v 6-1 -7;
befwe Janua a�rd11(�l r e year
tbe de t• e tiue�ITOn �
GIBb N ww. � , .._
If owned with sameone
indicate with whom
Is lhe property
spouse,
❑ Real property � Mobile home (I.C. 61-1-7)
Record number Page number
�e�alue of the property as of March 1, wrrenl year (may not
exceed $69,000)
Does the combined annual adjusied gross income o( fhe appliwnt and any
individuals sharing ownership exceed 525,000?
❑ Yes o
❑ Yes ❑ No �
INVe certify under penalty of perjury that the above and foregoing information is true and correcl and that lhe applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
n
r
/r�/l�. ���vr� l
s of applicant -� � / -
5� i �f/// /� •�d�..S� �
aulhorized representative