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,�___ '� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
° REQUESTING DEDUCTION FROM ASSESSED VALUATION
� � State Fofm 43708 (R4 / 10-01 �
�•• Prescnbed by Ne Department of Local Govemment Finance
mation wnfained in Ihis document is CONFIDENTIAL pursuant to IC 6-7.7-12-9.
COUNTY I TOWNSHIP I YEAR
INSTRUCTIONS: FILING DATES:
To be �led in person or by mail with the County Auditor of the county where 1) Real property: Dun�e 1r2 Qio�Q�}�efore May
the property is located. 11 / th d d t' ' t b 1f f
See reverse side /or additional instruction and qualifications.
Is applirant Ne sole legal or
whal is his/hdr exact share or interest?
�s ❑No I
If name on record is difterent than ihat of applicant, indicate below
Name of wntrad seller (app/icant must have been buying on contract at least one (1) yearJ
conUact
,
v� ' J •
property used and ocwpied 'marily (or
r residence?
the applicant 65 years o( age or more on
to the current year?
es ❑ No
:mber 31 of the year
� ❑ No
iPS date
/ a surviving, unmarried spouse, what was ihe spouse's age at
of death?
you filed for any olher deduc6ons?
SYes O No
you filed for deductions in any other county?
o e year e e uc �on is q e e ec rve.
2) Mobile ho assessed nd r�.C.6-1�
between J J,5 �?3 p ar
the dedu ho�! � CWe. ��,JpITOR �
It owned vnth someone olhe� than spouse.
indicate wilh whom
Is the property in question:
a property ❑ Mobile home (I.Q 61J-n
Record number Page number
V
Assessetl value oi Ne property as ot March 1, current year (may nof
exceed 869,000)
Does the combined annual adjusted gross income o( Ne applicant and any
individuals sharing ownership exceed 525,000?
of Income
Rvhat deductions?
whatcounry7
$
$
TOTAL $
❑ Yes ❑ No
Amount of Income
❑ Yes ' Vo �
I/We certify under penalry of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 20
iature of applicant Signature ot authorized representative (by executed Power o/Attomey)
less of applipnt � Address of aulhorized reoresentative