HomeMy WebLinkAboutAge_Wallis4'rt •� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
'� ° REQUESTING DEDUCTION FROM ASSESSED VALUATION
�' ,��� ✓ State Fartn 43708 (R6 / 4-04)
Prescribed by ihe Depanment ol Local Govemment Finance
�iation wntained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9.
INSTRUCTIONS:
To 6e �led in person or 6y mail with the County Auditor of the county where
the propeRy is located.
See reverse side for additional instruction and qualifications.
COUNTY 1 TOWNSHIP
l�
YEAR
FILING DATES:
1) Real propeEt� �uA�ng�ti�months 6e%re May
11 of the year the deduction is to be effective.
2J Mobile horr� assessef!-under I.C.Ef-1-7;
i,.-ti. c; .�-F
between January- 5 and�lVlarch 31 of the year
the [(§�(ip� ' ��eftel�va�F
Name of applicani ow r contract buyer) 1�� �
rY
Is applicant the sole legal r equitable ef.� If No, what is hislher exact share or interest? if owned with someone other than spouse,
indicate with whom
es ❑ No
If name on record is different th that of applicant, indicate below
Name of conVact seiler (ap 'cant must have been buying on contract at leasf one (i) year) �
Address of conVact selle Is the property in questlon:
eal property ❑ Mobile home (I.C. 6-1-1-�
Taxing disfri Key number / Legal description Record number Page number
�1�' —(�307 3 -pc�
Is the property used and occupied primarily for Assessed value of the property as of March 7, current year (may not
hisRier residence? exceed 5744,000J
es ❑ No
Was the applicant 65 years of age or more on Dece er 31 of the year poes the wmbined annual adjusted yross income of the applicant and any
prior to the curtent year? . individuals sharing ownership exceed $25,000?
es ❑ No ❑ Yes ❑ No
AppliwnCS date of birth (
$ �o�
I( (Jed by a surirving, unmarried spouse, what was the spouse's age at $
the 6me of dealh?
TOTAL $
Have you filed tor any other deductions? If Yes, what deducUons?
❑ Yes No
Have you filed for deduUions in any other county? If Yes, what county7
❑ Yes o
IJWe certify under penalty of perjury that the above and foregoing information is true and correct and thal the appiicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant Signature of authorizeC represeniative (by executed Power olAttomeyJ
�•� i i I��,�.2c,A�
ess of applicant Address of aulhorized representative
� I , �_ �