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4 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNrv TOWNSHIP vea,R
. REQUESTING DEDUCTION FROM ASSESSED VALUATION
�' State Fwm a3708 (RS / 6-03)
• Presaibed �y the Department of Local Govemment Finan "
Intortnation contained in this document is CONFIDENTIAL pursuan o C�.t�h2 ,-9. ��
File Mark
�fRUCT10NS: O T � Z003 FILING DATES:
To be filed in person or 6y mail with the County Auditor o! the coun� ivherc! 1) Real property: During the 12 months before May
the property is located. 11 0/ [he yea� the deduction is to be e(fective.
Mobile homes assessed under I.C.6-1-1-7;
See reverse side for additional instruction and qualifications G�gSON COU T Y qUDITOR between January 15 and March 31 of the year
[he deduction is to be eBective.
ame of applirant (o� er or con[2ct buyer)
�
apolicant ihe s� epal or eouitable owneR
�Yes ❑ No
name on record is diRerent th n Nat of aooliwn
or
Name oi conVact seller (applicant must have been buying on contract at least one (1) yrear)
of conVact seller
residence?
❑Yes ❑No
� the applicant 65 years of age or more on December 31 of the year
r to the current year?
�Yes ❑ No
�IicanYs date of biM (month, day, year) �
�-
=d by a surviving, unmarried spouse, what was the spouse's age at
Ume ot death?
you fileC for any
you filed for deductions in any
❑Yes ❑No
❑ Yes ❑ No
I vnN someone other than spouse,
with whom - -
property
❑ Real property ❑ Mobile home (I.C. 6-1-1-n
ASSe55e0 value of Ne property as of MarCtl 7, curtent year (may not
exceed 8144, 000)
Does the combined annual adjusted gross income of the applicant and any
individuals sharing ownership exceed 525,000?
❑Yes ❑No
Source of Income Amount of Ineome
$
E
TOTAL I $ rn�
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 aforementioned property on March 1, 20 _
X
of authorized representative (by executed Powe� of Attomey)
t Address of authorized representative
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