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' AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cour+rr TOWNSHIP r�
REQUESTING DEDUCTION FROM ASSESSED VALUATION
� ,M / State Fam 43708 (R7 / 5-OB)
Presv�bed by the Departrtient of Lod Govemment Financc
Fi e Mark
aUon contained in this document is CONFiDENTIAL pursuant to IC 6-7.1-12-9 and IC 6-1.7-359.
OCT 1 1 2007
� INSTRUCTIONS: FILING DATES:
To 6e filed in person or by mail with fhe Counfy Auditor of the county where 1) Real property: ��th�e, ��+onths before June
the property is located. 71 of the year th� d�tl�tion si� be effective.
� 2) Mobi/e h�gg���qPPde06lS6r'�-7-7�
See reverse side for additional instruction and qualifications. between January 75 and March 31 of the year
the deduction is to 6e effective.
Name of ppGcant (owner or con6aG buyerj �
/ ' `
Is appl nt the sole legal or equitaWe owneR
❑Yes ❑No
B name on record is different than that of applican
contract
Address of contrad
.
roperty used and ocapied
residence?
mus! have been
the applkant 6S years ot age a more on
to the arrent year?
No, what is hislher exac[
om m�hact
0
(1) year)
Keynumber/Legaldescription
N�-f3 -35- 300 _aao6
. hssessed value of
� exceed 5144,000)
❑Yes ❑No
the year
❑No
AppGpnYs date of birih (month, tlay, yearJ '
If filed by a surviving, unmartied spouse, what was tlie spouse's age at
the Urtre of deathl �
1'�
1'L•i'i
any other
�Yes
any other county?
If
I wiM someone other than spouse,
with whom
Is the property in question: �
LyReal property �lobile home (I.C. 6-14-7)
Recad number Page number
ie property as of March 1, wrtent year (may nof
�he combined annual adjusted gmss income of the applicant and any
uals sharing ownership exceed 525,000?
❑Yes ❑No
$
whal wur. c—_^ - - �/i/--/J�%_
X/ I���/< <i�/
❑v� uNo �
INVe certify under penalty of perjury that the above and foregoing info•**�����n is tn'
of Indiana and owner of the aforemeniioned property on March 1, 20 _
gnatu^ra d applican[ Signamre of authi
�/ I I � , i .. A
ot
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