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dj='"o AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courirr TOWNSHIP VEAR
s! �� REQUESTING DEDUCTION FROM ASSESSED VALUATION
• State Form a3708 (R / 9�96)
�"}�"�• Prescribed by �he State Board of Tax Commissioners
Information coniained in this documem is CONFIDENTIAL pursuam to IC 6-1.1-72-9. File Mafk
INSTRUCTIONS FOR FILING: � 1+ �' t`il� + `
To be liled in person or by mail with the County Audiror ol the counry where the property is loc�.� ��. ,j_ii:,,�
ted during the 72 months belore May 77 0/ the yea� the deduction is to be etfective.
Deductions lor mobile homes not assessed as real property must lile between January 75 and «Y �� 2���
March 31.
See reverse side for additional instruction and qualifications. � /� „
9
name on
a�
or equ� a le owner?
S C7 No
am than ihat of applicanL
oplicant must have been
the applicant 65 years of age or more on
to ihe turrenl year?
exact
on contract at least one
kUCITOR
If owned with someone other ihan spouse,
indicate with whom
Key number / Legal tlescripiion Record number Page number
�o� ooass-o�
Assessed value of ihe property as of March 1, current year (may no(
exceed 521.000)
es ❑ No ❑ Yes �#�
mber 37 of the year poes the combined annual adjusted gross income of the applicant and any
individuals sharing ownership exceed $20.000?
�
Have you
deductions in any other
❑ Yes L�-r�vo
❑ Yes L41Go
❑ Yes ❑ No
of Income Amount af Incoi
�cr'vt $ / 7a�0
tl Yes, what deductions?
If Yes. what wunty?
$
TOTAL � $
IlWe certify under penalty of perjury that the above and foregoing information is true and correct and ihat the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 19
ot applicani
� Tr' /-� (
/3N�
tN
of authorized representative