Age_Fleming�'��"s AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
�� REQUESTING DEDUCTION FROM ASSESSED VALUATION
State Fo:m 43708 (R6 / 4-04)
•• Prescribed by Ne Department of Lowl Govemment Finance
�rtnation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9.
COUNTY TOWNSHIP YEAR
�h6
v
File Mark \"
MAR 1 2005
INSTRUCTIONS: FILING DATES: ,.
To be filed in person or by mail with the CountyAudito� o( the county where 1) Real property: the 1,$ nths be(ore May
the property is located. 11 of the year th lb�i� be ef/ective.
2) Mobile hqr,��� pr�rd�U�'1'7;
See 2verse side for additional instruction and qualifications. between Tanuary 15 and March 31 of the year
the deduction is to be eHective.
Name of applicani (owner or contract buyer)
`
Is applicant the sole legal i le ownel?
p Yes ❑ No
If name on record is difterent than ihat of anolican
wntracl
wntract
musf have been
hisfier exact share or interest?
on contract at
�'Yes ❑ No
the appliwnt 65 years of age or more on December 31 gf the year
to ihe current year? �
date
year)
O No
� � .��
(Jed by a surviving, unmartied spouse, what was the spouse's age at
e time ot death7
you filed for any other tletlucU�
you filed for deductions in any
❑ Yes ❑ No
one
$744,000)
i wrtn someone otner tnan spouse,
with whom
the property in question:
❑ Real property ❑ Mobile home (I.C. 6-7-1-�
property as
year
combined annual adjusted gross income of the applipnt and any
s sharing ownership exceed $25,000? /
Source o Income
. $
$
TOTAL I $
❑ Yes (�fQo
Amount of Income
❑ Yes ❑ No �
I/We c ify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of In ana and owner of the aforementioned property on March 1, 20 _
ure of a/p�plicani � Signafure of authorized represeniative (by executed Power o/Attomey)
L / � A w � ��// �