HomeMy WebLinkAboutAge_Pollack� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, �� cout+rv TOWNSHIP v�
REQUESTING DEDUCTION FROM ASSESSED VALUATION
M� Slate Form 43708 (R7 / 5-06)
Presrnbed by t�e Departrnenl of Local Gwemment Finance �
File Mark
Information coniained in this document is CONFIDENTIAL pursuant to IC 6-1J-12-9 and IC 6-�5-
� `\
INSTRUCTIONS: FILI���E�6: 007 `
To be filed in person or by mail with the County Audiror o/ the county w6er� �� 7) I p oper�y: Dudng the 12 months e ore �une
the property is located. p �� 11 0( the ye e deduction is to be effeciive.
�y � '� 2J /� ���sessed under I.C.6-1-7-7;
See 2verse side /or additional instruction and qualifications. ✓r� h{� G18�� ��j���'Q��d March 31 0/ the year
��� uchon is to be effective.
(l
Name of applicant (ovmer w contrad buye� � -�
irant th$sole legal or equ'hable ovmer?
�
�Yes ❑No
� on record is ditlerenl an at of applipnt,
of contraG seller (applicant must have been
;s oi contraG seller
distric o
�����_�_
property used and occupied pnmariy for
buying on con6act at least one
number / Legal description
❑Yes ❑No
: the ap�nt 65 years of age or rtrore on December.37 of ihe year
r to the wrtent year? .
�Yes ❑No
dicanCs date oi birth (month, day, }rear)
ed by a surviving, unmarried spouse, what was iFie spouse's age at
time of death7 - ��
YW
you
any other deducbms?
in any other county?
�Yes
❑Yes ❑No
,,
w interes[?
If owned with someone
irMicate with whom
Is ihe property
value of the property as
spouse,
pmperty ❑ Mobile home (I.C. 6-74-7)
number Page number
of March 1, curtent year (may nd
ie combined annual adjusted gross income
ials sharing ownership exceed $25,000?
I/We certify under penalty of perjury ihat the above and foregoing info�**+�+��n is true and correct and that the applicant was a resident
of Indiana and owner of lhe aforeme�tioned property on March 1, 20 _
of authorized
�� iAddress of applinnt Address of authorized representalive
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