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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
State Fortn 43708 (Rfi / 4-04)
Prescribed by ihe Depanment of Local Govemment Finance
COUNTY I TOWNSHIP I YEAR
�nation contained in this document is CONFIDENTIAL pursuant to IC 6-7.1-72-9 and IC 6-7.1-35-9. B
lNSTRUCTIONS: FILING�E� ����
To be filed in person or by mail with the County Auditor of the county where
the property is located.
See reverse side for additional instruction and qualifications.
1) Real prop�y�uting t���� months 6efore May
11 of the year he deduclion is to be ef/ective.
2) Mo e homes as ess"�il unde I.C. 1-1-7;
be een Jane�a 15 PMrla 3 f the year
� tiJ�i �, � . �UJi R
Name of applicant (owner or con(ract b�yer) �
� �_ --��"'� =� .
Is applipnt the sole I I or equitable o�mer? If No, what is his/her exact share or interest? � If owned with someone other than spouse,
' indicate wiih whom
'pn'� ❑r,o
If name on record is diRerent than that of applicant, indicate below
Name of conVact seiler (applicant must have been buying on contract at least one (i) year)
Address of conVad seller Is the property in question:
U�Reaf property ❑ Mobile home (I.C. 6-1-1-7)
Taxing districl Key number / Legal description Record number Page number
� �pa 1- Oo 50 �I�--c�
Is�Ne property �sed and occupied primarity for Assessed value of the property as of March 1, currenl year (may not
hismer residence? exceed 3144,000)
�Yes � No �1 v � � �
Was the applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the current year? individuals sharing ovmership exceed $25.0001 � �
�'S'es ❑ No L�VS'es ❑ No
ApplicanCs date of birth (month, day, year) Source of Income Amount of Income
��
spouse's age at � $
the time of death?
TOTAL $
Have you filed for any other deductions? If Yes, what deductions? .
❑ Yes L�No
Have you filed for deductions in any other county? If Yes, what counlyl
❑ Yes �lo
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforemenlioned property on March 1, 20
Signature of appliwnt Signature of aulhorized representative (byexecuted Powe�ofAttomey)
ess of appiiwnt Address of authorized represenWtive
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