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�. AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
� �w � State Form 43708 (R7 / 5-06)
� Presrnbed by the Departr�ent of Loral Gwemment Finance
In ormation contained in this document is CONFIDENTIAL pursuani to IC 6-1.1-12-9 and IC 6-1.7-359.
GOUNTY TOWNSHIP YEAR
File Mark
INSTRUCTIONS: FILlNG D
To be filed in person or 6y mail with the County Auditor of the county where 1) Real p rty u ng th m th efore June
the property is located. 11 of t year�he�c on '�Kective.
2) Mobile homes assessed unde�6-1-1-7;
See reverse side (or additional instruc[ion and qual�cations. between Ja� !t5 �n� Jyj�ch 31 of the year
the deduction �s to��e e�'c4(Le.
applicant
or conVad buyerJ �
�
or equitable owne(?
�es ❑No
name on record is different than
(applrcant must have been
Cil
Foperty used and octupied
residence?
the appl�icant 65 years ot age or rtrore o�
ro the arrent year?
etl by a Survm�
6me of death?
P''�'
Have you
th (month, day, yearJ
u�married spouse, whai was
' �./L// l.L J'f��// l.
No, what is hisRier exact share w
��.icate below
on
��
one (1) year)
AUDITOR
If owned wiM someone other Nan spouse,
indicate vrith whom
- Is the property in question: -
e I property ❑ Mobile home (I.C. 6-1-1-�
Legal descriptlon Record number Page number
� 1a-Iu7-o�.�'7 �a
. Assessed value of ihe property as f March 7, wrtent year (may nof
ezceed 8144, 000J
No
year Dces the combined annual adjusted gross income ot the appiiprrt and any
individuals sharing uwnership exceed $25.000?
❑No
age
afry other deductions?
�Yes �No
deductions in any other county?
Ff Yes, what deductions?
what
�es ❑No I
I/We certify under penalty of perjury that the above and toregoing infc�=+��n is true and correct and that ihe applicant was a resident
of Indiana and owner of Ihe aforementioned property on March 1, 20
qnature of applican[ � � /J „ Signature of authorized representative (by executed Power oiAttomey)
1