HomeMy WebLinkAboutAge_Stone'�° ,� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
': -, ; REQUESTING DEDUCTION FROM ASSESSED VALUATION
,���! State Fortn a3708 (R3 / &OO)
Prescribed by ihe State Board of T� Commissbners
I�ation coniained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS FOR FILING:
To be filed in person o� by mail with the County Auditor of the county where the property is loca-
ted during the 12 months befo�e May 11 0/ the year the deduction is to be effective.
�IB/�NT�UDITOR
COUNTY � TOWNSHIP � YEAR
11AK U o [UU I
Deductions (ormobile homes not assessed as real praperty must file between January 15 and
March 31.
See reverse side lor additional instruction and qualifications.
Name of applipnt (owner or con6ac buy )
� ` _ �7
Is ap licant the ole legal or equitable owneR If No, what is hisRier exact share or interest? If owned vrith wmeone other than spouse,
..• indicate with whom
❑ Yes ❑ No
If name on rewrd is diftn.rent than that o( appliwnt, indicate below
Name of wnGad Iier (ap licant must hava been buying on contract at least one (1) yea�
Address of contrad s Iler
Tauing di i Key number / Legal descriptlon Recorcl number Page number
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Is the real p operty used and occupied Assessed value of the property as ot March 1, wrrenl year (may not
primarily for his/her residence? exceed 569,000)
es ❑ No 33 �
Was the applicant 65 years of age or more on December 37 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the current yeafl individuals sharing ownership exceed $25,000?
❑ Yes ❑ No ❑ Yes ❑�No
Applicant's date oi birth (
- � /( $ ��%
If filed by a surviving, unmarried spouse, what was the spouse's age at "� $
the Gme of death?
TOTAL $
Have you filed for any other deductions? If Yes, what deduc6ons?
❑Yes ❑No
Have you filed for deductions in any other county? If Yes, what county?
❑ Yes ❑ No
IM/e certify under penalty of perjury lhat lhe above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant Signature of authorized representative (by executed Power olAttomey)
1 � ��(L,r
�ss of appliwnt Address of authorized representative
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