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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cour+n TOWNSHIP v�aa
REQUESTING DEDUCTION FR�A�S�SSED VALUATION
� �� � State Fum 43708 (R7 / � ��
P2smbed by tl�e Deparbnent �t ��
File Mark
Informalion contained in this document is ONFIDENTIAL pursuant IC 6-1.1-72-9 and IC 61.1-35-9.
INSTRUCTIONS: AF� 1� 11j11� FILING DATES:
To be filed in person or by mail with the County Auditor�f the;counry where 1) Real property: During the 12 months before fune
the property is located. �. `!�-"� ' ,,' 11 of the year the deduction is to be effective.
� `l N' V'�" '� ��� 2) Mo6ile homes assessed under I.C.6-1-1-7;
��gj�'`� y� 6etween January 75 and March 37 of the year
See reverse side for additional instruction and qual�cations.
the deduction is to be effective.
mntrad
or
It No, what
❑Yes ❑No f
t( name on recoid is diRerent than ihat of apptinnt, indicate 6elow
Narne of contract seller (applicant must hava been 6uying on contract
or ��a
hislher residence?
Was the applicant 65 yea
priw to the current year?
AppliranYs data
tlie spouse's age at
you filed fw any ofher deductions?
you filed for deductions in any other
❑Yes ❑No
one
description
u
If owned with someone other Nan spouse,
irMicate with whom
property in Question: �
❑Real property ❑ Mobile home (I.C. E1-1-�
Record number Page number
of the property as
sharing
what
year (may rwt
and
Source of Inwme Amount oi Income
$^��
$
TOTAL $
Yes, what county?
❑Yes ❑No I
IlWe certify under penalty of perjury ihat the above and toregoing info�+*�=t��n is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
gnature of appticant Signature of auMorized representative (by executed Power olAttomey)
� /, l , ��
of
�
representative