HomeMy WebLinkAboutAge_Wills;_^ •� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
` iQ REQUESTING DEDUCTION FROM ASSESSED VALUATION
S � State Fortn 43708 (R6 / 40a) �
Preuribed 6y Ne Depanment of Local Gwemment Finance
�rmation wniained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1•359.
INSTRUCTIONS:
To 6e �led in person o� by mail with the County Auditor o( the county where
the property is located.
See reverse side /or addifional instruction and qualifications.
Name o( a licant (owner or
Is appiicant the wle teg or
If name on record is diRerent
Address of contraM seller
� . ��J�G.%�!f
ovmer! - � �� ir rvo. w��a� �,
❑Yes ❑No �
than fhat of aoP�icant, indicate
musf have been buvma on
and occupied primarily
Was the applicant 65 years of age or more on
prior to the wrrent year?
of birth (monfh, day, year)
exact
a�-i� - is -ani-
Key number / Legal de
�� �
Gme of deaih?
Have you filed (or any other deductions7
you
any
one
or
COHN�Y�.. _jOWNSHIP YEAR
�� � '�
FEE �����J�
FILING DATES: ,�
1) Real propeRky: D/u�nnrg the" 92 �ths 6elore May
11 of the y�eartrthe rTe"duCtlnn is�ta � eNective.
2) Mo6ile homes assessed under I.C.6-1-1-7;
between January 15 and March 31 of the year
the deductron is to be eNective.
'�, wiih someone other than spouse,
wifh whom
Is the praperty in question:
� 7��O ❑ Real property ❑ Mobile home (/.C. 6•7-7-7)
- 031��-00�
Assessed value of the property as ot March 7, current year (may not
exceed 3144,000J
❑ No
he year poes the combined annual adjusted 9ross income of the applicant and any
individuals sharing ownership exceed 525,0007
�ja'Yes ❑ No �
$
1/VJe certify under penalty of perjury that the above and foregoing information is lrue and correct and that the applicant was a resident
of Indiana and owner of the aforementioned propeRy on March t, 20
3nature of appliwnt Signature of authorized representative (by executed Powe� olAttomeyJ
n i
ot applicai
�oa