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�'� AFFiDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, TO P Y� \
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�' �� � State Farm 43708 (R7 / SO6)
P�esmbed by the Dep�artrnerM o( Local Gwemment Finance
de
.....,rmalion contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
INSTRUCTIONS: FILING DATES: � '��'
To 6e filed in person or 6y mail with the County Auditor of the counry where 1) Real proper(}}�{$(ryF�7 �i�lfiddlii�T��iire �une
the property is located. 17 of the year the deduction is to be eflective.
2) Mobi/e homes assessed under I.C.6-1-7-7;
See reverse side !or additional instruction and qualifications. 6etween January 15 and March 31 of the year
the deduction is to be effective.
w conhact
owneR If No, what is hislFier exact share w interest? If owned with someone other ihan spouse,
indirate with whom
R f13m8 on fECOfO Is amCfenl Ulan Ina� �
Narne af contraG seller (applicant must
�
Address of conVact seller
❑No I
oPlicant, indinte below
on contract at least one
the property usetl and oauwea pnmanry tor
✓her residence7
❑Yes
as the ap�nt 65 years oi age w more on December:3�
or t0 the arrent year? �f
,�{Yes
��' � �
ed by a survrving, unmartied spouse,
time of death?
}rou filed fw any other
was
dp -/�'
!o
p
e
ONo
f the year
$
❑Yes ❑No �
I/We certify under penalty of perjury lhat the above and foregoing info�����n is true and cortect and thal the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
j � ��✓,
- --Iress ot aPqicant� � � *7 � 6 �
I ���OS, /0�.5E ���l�ho�G'i�
�=
of auMorized represenfative
representative