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� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNrr TOWNSHIP v�aa
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S,� % State Fortn 43708 (R7 / 5-06)
Presmbed by Me Departmem of Loal Gwemment Fu�an�x
File Mark
�mation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 61J35-9.
OCT 1 1 2007
INSTRUCTIONS: FILING DATES.�
To be �led in person or by mail with the County Auditor o/ the county where 1) Real properry`�, tF��onths before June
the propeRy is located. 17 0/ the yea� the d�uc6o to be e8ective.
2J Mobile�l�fi�f�A�d�'uAtl�N7@R6-1-7-7;
See reverse side fo� additional instrucfion and qualifications. between January 15 and March 31 of the year
the deduction is to 6e effective.
appllCdfiJ'(l185o1e legal or
/
name on record is d"Aferen
ame of contra4 seUer (aPF
ddress of conVaG seller
❑ No
oF appfinnt,
' P�PenY used and ocapied PrirNanly for
u residence?
the applirant 65 years of age w more o� 1
to the wrrent year?
icant's date oi birth (month, day, year)
/—��— �
filed by a surviving, unmartied spouse,
e time of death7
Have you
other deductions?
buying on contract at least one
w interest? If owned vriUi someone oNer inan spouse,
irMipte with whom
Is the property
eal property ❑ Mobile home (LG 6-74-�
imber! Legal desaiption Recad number Page number
d3o.���00 oc�da'9�o/
. Assessed value of ihe property as of March 1, wrrent year (maY rwf
� exceed 8744,000)
❑No
1 of the year Dces the combined annual adjusted gross income of the applinnt and any
individuals sharina ownershio exceed E25,000?
❑ No
was ihe spouse's age at
DYes ❑No
any oiher cwnty?
�Yes ❑No
If Yes, what munt�?
�Yes ❑No (
I/We certify under penalty of perjury that the above and toregoing info��t��� is true and correct and thai the applicani was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
1 of ap icant �
/6 O �/s ,5
EL I? ER �E
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SR.57
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