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.
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 � ��// �