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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cour+rr TOWNSHIP vEO,R
REQUESTING DEDUCTION FROM ASSESSED VALUATION -
sraca Form a3�oe �txs i s-oa�
Prescribed Cy ihe Department of Local Govemment Finance
Infortnatlon contained in this document is CONFIDENTIAL pursuant to IC E7.7-12-9.
�"RUCr10NS:
To be filed in person or 6y mail with the Counry Audito� o/ the county where
the property is located.
See reverse side /or additional insVuction and qualifrcations.
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FILING DATES.'' 1` - - �` -'--J
1) Real property: Dun�j9�er12 m'o,r� before May
11 o(the yeartherdeducNon�i� effective.
2J Mo6ile homes assessed under I.C.6-1-1-7;
beM1Veen January 15 and Maich 31 0( the year
the deductio`n,is to tie;eflective.--�(,�c,�
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Name of applicant (owner or cont2cf buye�
-�-•_ _- -;� -- 4�
Is appliwnt the so e eaa or equitable'owrier If No, wha is hishier
whom
S ❑ No
If name on record is ditferent than at of applicant, indicate below
Name of contract seller (applicant must have been buying on contract at least one (1) yrear)
Addreu of conVact seller Is the property in quesUon:
eal property ❑ Mobile home (I.C. 6-1-7-�
Tauing district Key number I Legal descnpiion R cord number Page number
�- - �b
tie property used and occupied primarily for � �—'ASSessed value o( Ne property as o( March 1, curtent year (may not
er residence? exceed $144,000J
S ❑ No
Was Ue applicant 65 years of age or more on December 31 of the year
� �
Have you filed for any oNer deductions? If Yes, what deducGons?
es ❑ No
Have you filed for deductions in any oNer county? If Yes, what county?
❑ Yes �tao
INVe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resideni
of Indiana and owner of the aforementioned property on March 1, 20 _
Signa[ure of applicant Signature of authorized representalive (by executed Power o7Attomey)
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Add e of app�' nt Address of authorized representative
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