Age_Coxn�*
� F AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cour+rr TOWNSHIP venR
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S Sfata Form a3708 (R5/ 603)
uu
Ptasuihed by the Department of Local Govemment Flnance ��
•�nrmation contained in ihis document is CONFIDENTIAL pursuant IC 6-� t$9. File Mark
�TRUCTIONS: � FILING DATES:
7o be filed in person or by mail with the Counry Auditor of the count��rel 6 Z003 1) Real property: Dunng the 12 months before May
the property is located. 11 o/ the year the deduction is to be effective.
�t2)� A�obile homes assessed under I.C.6-1-1-I;
See reverse side /or additional insfruction and quali�cations. ,/� ��� .�^�`tr�tween January 15 and March 31 0/ the year
GIgSON Ca�n' Y nVt71?9P�he deduction is to be eHective.
or
or
❑ Yes ❑ No I
name on record is diRerent than ihat of applicant, indicate below
on
convaa
disVict
property used and occu�led primarily for
�.r residence?
❑ Yes ❑ No
Was ihe applicant 65 years of age or more on December 31 of the year
p�orto lhe wventyear? ` �
�LYes ❑ No
AppliwnYs date of biAh (month, day, year)
� -
the spouse's age at
the tlme ot death?
you
you filed
❑ Yes ❑ No
any other county?
❑Yes ❑No
exatt Shafe Or
I wiN someone
with vfiom
praperty
spouse,
❑ Real property ❑ Mobile home (I.C. 6-7-1-n
Assessed value of the property as
exceed S t 44, 000)
combined
s sharing
If Yes, what
If Yes, what wunty?
March 7, wrtent year (may not
3ross income of the applirant and any
1525,000?
❑Yes ❑No
Amount of Income
�
$
TOTAL 5 �c
I/We certify under penalty of perjury that the above and foregoing information is true and conect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature
�
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