HomeMy WebLinkAboutAge_Walkerr���� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR M.ORE, courm TOWNSHIP vea,R
r� '4 REQUESTING DEDUCTION FROM ASSESSED VALUATION I
��° � Stata Fortn a3708 (R6I4-0a) �
� • Prescribed by the Depariment at Lowl Govemmant Finance
Informa6on contained in this document is CONFIDENTIAL pursuant to IC 6•1.1-72-9 and IC 6-1.1-35-9.
Fit ar�
INSTRUCTIONS: FILING DA� � �
To be filed in person o� by mail with the CountyAudito� of the county where 1) Real property: Qu!�ng the 12 months before May
the property is located. 11 of the yearQherdeau�tiopQ�7o be effective.
2) Mobile homes assessed under I.C.6-1-1-7;
See reverse side for additional instruction and qualifications. between January 15 and,March 31 of the yea�
the deduction ls�to'Yfe e`flec6ve.
or convact
applicant the sole legal or
No,
/�
�f.Yes � No �
name on recorcl is difterent than thal o( applicant, indicate below
Address o( conVaIX seller
'�xin9 ��/lA
/�l
15 the property used and occupied primarity for
hisfier residence?
Was lhe applicant 65 years ot age or more on De i
pnor to the current year7
ApplicanPs date of birth (month, day, yearJ
�-�-
If filed by a surviving, unmartied spouse, what was
the tlme of death?
Have you filed for any other deductions?
you
any
rylRg'on contract af least one
Key number / legal descriptic
02(0-/01-07-400i-
-Q �
A
ex
' a'es O No
iber 31 of the year Dc
in�
�s ❑ No
�e spouse's age at
❑ Yes
or
o5q-
wmbined
s sharing i
with someone other ihan spouse,
with whom
property in question: �
29-R€al property ❑ Mobile home (I.C. 6-1-7-�
Record number Page number
�erty as of March i, wrtent year (may not
0 97vo
adjusted gross income of the appliwnt and any
Source of Income
$
5
TOTAL S
Yes, what deductions?
whatcounry?
O Yes
Amount o Income
❑ Yes C�No �
IPNe certify under penalty of pery'ury that the above and foregoing informalion is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned propeRy on March 1, 20 _
3nature of applicant � Signature ol authorized represenialive (6y executed Power ofAttomev)
���� �� c^� ��2:e�
�ss of applicant ,
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