HomeMy WebLinkAboutAge_Tooley�A AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
:- � REQUESTING DEDUCTION FROM ASSESSED VALUATION
S , Slate Form 43708 (R3 / &00)
'•O PresuiEeA by the State Board of 7ax Commissioners
ormation contained in this document is CONFIDENTIAL pursuant to IC 6-7.1-12-9.
INSTRUCTIONS FOR FILING:
To be filed in person or by mail with the County Auditor of the county where the property is loca-
ted during the 12 months be%re May 11 01 the year the deduction is to 6e eNective.
Deductions (or mo6ife homes not assessed as real praperty must file behveen January 15 and
March 31.
See reverse side for addi6onal instruction and qualifications.
COUNTY TOWNSHIP YEAR
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S � i t�•
MAY 1 g 2003
GI8/�J
n�TY AUDITOR
Name of applipnt (owner or contract buyer)
Is applipnt the sole legal or equitable owneR— IfNo at is hislher exad share or interest7 If owned with someone other than spouse,
, , indiwte with wham
es O No
If name on record is diBerent than that of applicant, indipte below '
F QOi
Name ot contract seller (applicant musf have been buying on oonhact at least one (1) yea�
Address of contrad seller
Tazing distrid Key number / Legal descripfion Record number Page number
� �J_-_-�i-=D�"�S_--�--� �
Is the real property used and occupied ` Auessed value of the property as of March 1, wrtent year (may rrot
primarity for hisTher residence7 exceed 569,000J
es ❑ No
VJas the applicant 65 years of age or more on December 31 of Ne year poes the combined annual adjusted grou income of the applicant and any
prior to the current yea� individuals sharing ownership exceed 525,000?
es ❑ No ❑ Yes ❑ No
ApplipnPs date of b�rtn (monfh, day,
�� $
If filed by a surv'rving, unmarried spouse, what was the spouse's age at $
the lime of death? �
��, TOTAL $ GC�
Have you filed for any other deductions? � If Yes, what dedudions?
Yes ❑No /�.d•
Have you filed for dedudions in any other wunty9 I( Yes, what county?
t
❑Yes ❑No
1/We certify under penalty of perjury thal the above and foregoing infortnation is We and correct and that the applicani was a resi-
dent of Indiana and owner of lhe aforementioned property on March 1, 20 _
Signature ot applicant Signature of authorized representative @y executed PowerofAttomey) .
J � J � �
ress of applipnt Addreu of authorized representative
�I � D �.