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ej �"o AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
` `= RE�UESTING DEDUCTION FROM ASSESSED VALUATION
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State Form a3708 (R / 9-96)
-��,�"' Prescribetl by the State Board of Tax Commissioners
Information contained in this document is CONFIDENTIAL pursuani to IC 6-1.7-72-9.
INSTRUCTIONS FOR FILING:
To be )iled in person or by mail with the Counry Auditor of the county where the propeRy is loca-
ted during the 72 months belore May i l o/ the year the deduction is to be eflective.
Deductions loi mobile homes not assessed as real property must lile between January 75 and
COUNTY TOWh�.IP � �.,�qR� ,
File Mark
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March 37. /`
See reverse side foi additional instruction and qualilications. (/ �/}J
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Nameofapplicant(ownerorcontrac(buyei) . � � - - -�'�-:..":,r.;��-.�? j
v �X�-Q�
Is applicant the sole legal or equitable owner? If , what is his/her ezact share of interesi? If owned with someone other than spouse,
indicate with whom
es ❑ No
If name on record is different ihan that of applicant, indicate below
Name of contract seller (applicant must have been buying on crontract at leas� one (1) year)
Address of contraci seller
I�Tazing disirict Key number / Legal description Record number Page number
I � a � _- A =•
Is the property used and occupied primarily for Assessed value of the property as of March t, current year (maynof �
his/her residence? exceed 521.000)
O No �c�s No
Was the applicant 65 years of age or more on December 31 of the year poes the combined annual adjusted gross income of [he appli nt and any
prior to the current yeaR individuals sharing ownership exceed 520,000?
❑ Yes ❑ No
Applicant's date of birth (month, day, ye J Souree of Ineome Amount ollncome
�- - $
It filetl by a surviving, unmarried spouse, what was the spouse's age at $
the time of death?
ITOTAL $
Have you filed for any other deductions? I If Yes, what deductions?
❑ Yes �No
Have you filed for deductions in any other wunty? If Yes, what couniy?
❑ Yes LJ No
I/We certify under penalty of perjury that the above and toregoing information is true and correct and ihat the applicant was a resi-
dent of In 'ana and owner of the aforementioned property on March 1, 19
Si nature plicant � Signature of authorized represeniative (6y executed Powei olAttorneyJ
�7 es/s �of Aapplicani ` s ' Address of authorized representative _
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