Age_Dewig (3)'. � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
` �� � State Form 43708 (R5l 6-03)
� Presaihed by the Departmem of Local Govemmant Finance
Informatlon conWined in ihis document is CONFIDENTIA� pursuant to IC 61.1-12-9.
INSTRUCTIONS:
To 6e filed in person or 6y mail with the CountyAuditor of the county where
the propeRy is located.
See reverse side for additional insWcfion and qualifications.
FILWC, DATES: .+,� n /'II'{
1J Real propert�Dunng the ttr➢�8nths befire May
11 of the year the deduction is to be ef�ective.
2) Mobile liomes assesse�bnder I.C.6-� 1-7;
beRVe�n%JaS� 15�H�`M1�a��the year
the ded�Pon �s to�e'effecfive: ""
Name of applicant (owner or confract buye� — 'C/
Is applicant Ne sol egal or equitable ownerT If No, what is hisRier exact share or i est? If owned vrith someone oNer than spouse,
indicare wiN whom
es ❑ No
If name on record is ditterent lhan that af applicant, indicate below
Name of contract seller (applicant m�sf Aave been buying on cont2ct at least one (1J year)
Address of conVaM seller Is the property in question:
�Real properry ❑ Mobile home (I.C. 6-7-7-n
T x' district Key number I Legal description Record number Page number
�6 =6-a�- __� =�cc�
Is ihe p rry used and occupied primarity for
$ �
Have you filed for any other deductions? If Yes, what deductlons?
❑ Yes LYNo
Have you filed for deduMions in any olher county? If Yes, what count�
❑Yes QNo
IIWe certify under penalty of perjury lhat 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 _
Sigqature of applicam � SignaNre of authorized representalive (by executed Power ol Attomey)
y�
(�
Adress of a pli t Address of authorized representative