Age_Martind"�" . AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
'.�- ,;g REQUESTING DEDUCTION FROM ASSESSED VALUATION
� State Fortn 43708 (R3 / 8-00)
S�ui, �
P re u n b e d b y t h e S t a t e B o a r d o f T a x C o m m i s s i o n e rs
I�ation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS FOR FILING:
To be �led in person or by mail with the County Auditor ol the county where the piape�ty is loca-
ted during the 12 months 6e%re May 11 olthe yearthe deduction is to be effective.
Deductions for mo6ile homes nof assessed as 1 pmperty must file behveen January 15 and
March 31.
See reverse side for additional instruction ap u ificatlons.
Is appliwnt the sole Iegal or equ
❑ No
name on
of contred seiler
� u.w� (3 I FI' f l�
d property used and occupied
tne applicant 65 years ot age or more on
to the current yeaR
or
conlract at least one (i) yea�)
COUNTY I TOWNSHIP
� ����
MAR 05 2001
W�m
wiM
YEAR
spouse,
y number / Legal description Record number Page number
.0-3 = o�0 2-8 ��o 0
�
�r 31 of the year poes the com6ined annual adjusted gross income of the appiicant ai
individuals sharing ownership exceed 525,000?
�Yes ❑No
R's dale of birth (
��
� a surviving, unmarried spouse, what was the spouse's age at
of death?
you filed for any other deductions?
you
F�'iYes ❑No
any othercounty7
❑ Yes � No
If Yes,
❑ Yes
Source of Income Amount
�2_�.,. � •
$
. $
TOTAL $
any
I/We certify under penalty of perjury lhal 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 _
ature of appliwnt Signature of author¢ed representative (by executed PowerolAttomey)
of authorized representative
�i1�
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