Age_Bottoms (3)_di—" t AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�` REQUESTING DEDUCTION FROM ASSESSED VALUATION
.,, :
•�� State Form a3708 (R / 9-96)
�" �, Prescri6etl by t�e State Board of Tax Commissioners
Informa�ion comained in ihis documem is CONFIDENTIAL pursuant ro IC 6-7.7-12-9.
INSTRUCTIONS FOR FILING:
To 6e liled in person or by mail with the County Auditor of the county where the property is loca
ted during the 12 months be%re May 77 of the year the deduction is to be eNective.
Deductions !or mobile homes not assessed as real property must lile benveen January 15 and
March 37.
See reverse side lor additional instruction and qualifications.
Name of applicant (owner or contract er) , � -�
nameon
comrad
contract
residence?
Or eqmlable o
❑ Ye5
ent ihan that c
Dolicant must
the applicant 65 years of a9e or more on
to the current year?
pplicanYs
filed by a s� iving, u� rried spouse �
ie time of death?
ave you filed for any other deductions?
you filed for deductions in any oiher
-1—
exaci �
on contract at ieast one
��v• �
y, i a'
� � � � �'�'
���
GIBSO�,�
It owned with someone other than spouse,
indicate with whom
number � Page number
0 0 -O -00
Assessed value of Ihe property as of March 1, wrrent year (may not
exceed $27,000)
Yes ❑ No ❑ Yes 1,-+�f�o
:ember 37 of the year poes the combined annuat adjusted gross income of the applicant and any
��� individuals sharing ownership exceed 520,0007
❑ Yes �.Ala�
$
❑ Yes .�"No �
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that ihe applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 19 _
ature of applicant Signature of authonzed represeniative (by executed Power olAmomey)
ess of applicani
,�,e�3
/o�
y7lo Uv
ot authorized representative