HomeMy WebLinkAboutAge_Whitehead (2)dj °�'ot AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
e REQUESTING DEDUCTION FROM ASSESSED VALUATION
. �� ;:
Slate Form 43708 (R / 9-96)
�"�'�,��' Prescribed by the State Board of Tax Commissioners
Intormation contained in ihis document is CONFIDENTIAL pursuant to IC 6-7.1-72-9.
INSTRUCiIONS FOR FILI(YG:
To be liled in person or by mail with the County Auditor ol the counry whe�e the property is loca-
ted during the 12 months belo�e May 11 of the year the deduction is to be effective.
Deductions lor mobile homes not assessed as real property must file between January 75 and
Ma�ch 37.
See reverse side lor additional instruction and qualitications. '�'
�:
Name of applican wner or conlrec� �
Is applicant the s legal or equitable
No, whai is his/herexaci share
� Yes ❑ No I
If name on record is ditterent than that of applicanL indicate below
cl seller (applicant must have been buying on contract at leasf one (7J yearJ
l�
ract seller
pmperty use
r residenCe?
ihe applicant 65 years ot age or more on
to the current year?
filed by a surviving,
e time of death?
you filed for any other
Key number / Legal description
O � - 03/ � S- -O�
es ❑ No
:ember 37 of the year
-
spouse, what was the spouse's age at
❑ Yes �
COUNTY TOWNSHIP YEAR
File Mark
1
P�!+; Cl i 7tiuJ
r.
I with someone other than spouse.
with whom
A55255Btl VdIUB 0� thB pfOpBRy d5 01 MdfCh 7, CUfrBn� yBar (rt1By /lot
exceed 527.000) � � � O �
1 ❑ Yes ❑ No
Does the combined annual adjusted gross income of the applicani and any
individuals sharing ownership exceed 320,000?
$
? you filed for deduciions in any other counry? It Yes. whal wunry?
❑ Yes L7No
I/VJe certify under penalty of perjury that the above and foregoing information is true and correct and ihat the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 79 _
�
represeniative (by execu(ed Power o7Attomey) .
,,`
plicani IAddress of authorized representative �
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