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`= AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
°� � REQUESTING DEDUCTION FROM ASSESSED VALUATION
> ,��� .� State Fortn 43708 (R6 / 4�04)
Prescnbed by the Department ot Local Govemment Finance
I�rtnation wntained in this document is CONFIDENTIAL pursuani to IC 6-1.7-72-9 and IC 6-1.1359.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o/ the county where
the property is located.
See reverse side !or addiG'onal instruction and qualifications.
ot applicant
applirant
contract
or equitable ownef.r � If No, what is
❑ Yes ❑ No
name on record is difierent than that of applican
contract
and
/
f
exad
or
must have been buying on contrect af leasf one (7J year)
cna -�a
❑Yes ❑No
� applicant 65 years of age or more on December 31 of ihe year
the cunent yeaR
❑ Yes ❑ No
ilicanl's date of birth (month, day, year)
spouse, what was the
time of death?
�e you filed for any other deductions?
�d • �
�e you filed for deductions in any olher countyl
age at
Yes ❑ No
❑ Yes
�iII`�i'���u'�� �
;�.`
, . � . ..
. �.
FILING DATES: �'r ��
1) Real prop��yri�q�tQrp�fore May
11 of the year the deduction is to be effective.
2) Mobile homes assessed under 1.C.6-i-1-7;
behveen January 15 and March 31 of the year
the deduction is to be effective.
�-oo
Assessed value of I
exceed 3144,000)
Does the combined
individuals sharing �
�
iwned wifh someone
licate with whom
Is the property in question:
spouse,
Real property ❑ Mobiie home (I.C. 6-1-7-�
�.cord number Page number
operty as of March 1, current year (may not
ial adjusted gross income of the applipnt and any
rship exceed 325,0001
❑ Yes �lo
e
IIWe 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 _
3nature of appliwnt Signature of authorized representative (by execufed Powe� olAftomeyJ
/�
Z j� y�cca
ofauthorized represeniative