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1� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNTV TOWNSHIP vea,a
REQUESTING DEDUCTION FROM ASSESSED VALUATION /�
S � State Fwm 43708 (RS / 6-03) � j(�
�• Prascnbed by the Department of Local Govemment Finance ��
���rff--���--�� File Mark
InformaUon wntained in this document is CONFIDENTIAL pursua to IC 6�,.1.�9. ��
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INSTRUCTIONS: �g� FILING DATES:
To be �led in person or by mail with the County Auditor of the counW,wh�4e 1) Real property: During the 12 months before May
the property is located. u�% � / 2�03 11 of the year the deduction is to be effective.
2) Mobile homes assessed under I.C.6-1-1-7;
See reverse side for additional instruction and qua(�catio s � between January 15 and Maroh 37 0/ the year
�J ��-�-�� tbe deductian is ro be eflective.
GIBSON OUfitY nUplTpq �
Name of applicant (owner or contract buye� .
�,�.c��. �_-- � -,
Is aoolicant the sole legal or equita6le owner? If No, what is hisRier exact share or interest? If owned with someone other than spouse,
indicate with whom
❑Yes ❑No
If name on record is difFerent than thai ot appiirant, indicate below
Name of conVact seller (applicant must have been buying on contract atleast one (1J }rearJ
Address of conVact seller Is the property in question:
❑ Real property ❑ Mobile home (I.C. 6-7-1-7)
'strict � Key_uumbet.!-legal�descripiion� Rewrd number Page number
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�D�o=t-oo-�=y �=o�
Is the property used and occupied primarily for Assessed value of Ne property as of March 1, curtent year (may not
hisTher residence? exceed $144,000)
es ❑ No
Was the applicant 65 years of age or more on December 31 the year poes the combined annual adjusied grass income of the applicant and any
prior to the current year? individuals sharing ownership exceed 525,000?
es ❑ No ❑ Yes ❑ No
ApplicanPs date of birih (month, day, year) ,
�
Have you filed for any olher deductions? If Yes, what deducUons?
❑Yes ❑No
Have you filed for deductions in any oNer county? If Yes, what county?
❑ Yes ❑ No
INJe certify under penalty of perjury that the above and foregoing information is true and correct and Ihat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant , Signature of authorized represeniative (by exeruted Power of Attomey)
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.,ddress of applicant Address of authorized representative
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