Age_Hollander� COUNTY TOWNSHIP YEAR
AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
. S M� State Form 43708 (R7 / 5-OB)
. � Pr¢srn'p¢d py (he Department of Local Govemment Fina�xe
I
Information contained in Ihis document is CONFIDENTIAL pursuant to IC 6-1 J-12-9 and IC 67.135-9.
INSTRUCTIONS: FILING DATES:
To 6e (led in person or by mail with the County Auditor ol the county where 1) Real propertB (Qyrirjg �eZ�Jr}�onths before June
the property is located. 11 of the year the deduction is to be effective.
2)Mobilehome� sesse� der1.C.6-1-1-7;
See reverse side /or additional instruction and qualifications. 6etween Ja�a'ry°�an�rch 31 of the year
the deBdBH�N�l0Y1mEYfetY1¢870R
i-'
of appGpnt
name on
contract seller
P�PQKY use
r residence?
owneR If No, what is
❑No
of applinnt, indinte below
on contrdct at least one
number
�����r�
�
❑Yes ❑No
the appiicant 65 years of age or more on December.31 of ea
to the current year?
s ❑No
iranCs date ot birth lmon[h. daV. Vear)
If filed by a survFAng,
the spouse's
any
❑Yes �No
a interesY?
S f 44, OOO)
sharing
If owned with someone oNer Nan spouse,
irMinte with whom
Is the properry in question: �
❑ Real pmperty ❑ Mobile home (I.C. 51-1-�
Record number Page number
❑Yes ❑No I
IIVJe certify under penalty of perjury tha[ the above and foregoing info�*+=i��� is true and correct and thai the applicant was a resident
of Indiana and owner of the aforementloned property on March 1, 20 _
representative (by execufed
representative