Age_HumeA� rt.rr4
�,,,... .`� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
'� '� REQUESTING DEDUCTION FROM ASSESSED VALUATION
�+ d State Fo(m 43708 (R6 / 4-04)
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COUNTY TOWNSHIP YEAR
Pres�ribed by �he Department of Lowl Govemment Finance '
.mation contained in this document is CONFIDENTIAL pursuant to IC 6-7.1-12-9 and IC 6-1.13&9.
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INSTRUCTIONS: FILI�� .
To 6e filed in person or by mail with fhe CountyAuditor o( the county where
the property is located.
See �everse side for additional instruction and qualifications.
1) Real pro e(fl'�Quqri� 12 months be%re May
11 of th �9�ehr f�iekf � on is to 6e ef/ective.
2) Mo6ile homes assessed under I.C.6-1-1-7;
behveen- �ua„ry��d March 31 0l the year
the ded ctfon�s to be�effective.
aIBSON COUNTY Aw1�vh
If No, what is hislher exact share or interest? If owned with someone other than spouse,
^ ' indicate with whom
❑ Yes ❑ No
Ii name on record is diBerent than that of applirant, indicate below _
Name o( mntract seller (applicant must have been buying on contract at least one (1J year)
Address of conVad selier Is Ihe property in question:
❑ Real property ❑ Mobile home (I.C. 57-7-7)
Taxing districl Key number / Legal description Rewrd number Page number
• 003-4o�a�-o�
Is the property used and occupied primarily for � Assessed vaiue of the property as of March 7, current year (may not
hismer residence? exceed 3144.000)
es ❑ No
Was the applicant 65 years of age or more on December 31 the year poes the combined annual adjusted gross income o( the applicant and
prior to the current year? individuals sharing ownership exceed $25,0001
es ❑ No ❑ Yes o
Applicanl'
$
Have you 51ed for any other deductions7 If Yes, what deducUons?
O Yes ❑ No
Have you filed for deductions in any other counry? If Yes, what county7
❑Yes ❑No
UWe 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 _
. �� Address o( authorized representative �
` .