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fro_, _`; AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR M.ORE,
" REQUESTING DEDUCTION FROM ASSESSED VALUATION
> ,.�. .� StaU Form a3708 (R6 / 4-0a) .
Presmbed by the Depariment af Lowl Govemment Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6•1.1•12-9 and IC 6-1.1-359.
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor of the county whe�e
the property is located.
See reverse side for additional instruction and quali�cations.
COUNTY TOWNSHIP YEAR
I
i rk
FILING DATES��Y .0 4 2007
1) Real prope unng the 12 months before May
11 of the year the deduc io is to 6e e1(ective.
2J Mobile home rl.C.6-1-1-7;
between Janu�x �1�� of the year
the deBr16�9d?Ns+tA4i�ec �ve.
Name of app� nl (owner o� conVact buyer) . �
�� ,�% . Cc�
Is applicant the sole Iegai or equitable owne(? If No, what is his/her exad share or interesl? If owned with someone other than spouse,
' indicate with whom
O Yes � No
I( name on record is diHerenl fhan Ihat of applicant, Indicate below
Name of contract seller (applicant must have been buying on contract at least one (1) year)
Address of contract seller Is the property in question:
❑ Real property ❑ Mobile home (/.C. 6-f•7-7)
raxing disVict � Key nurpber / Legal description Record number Page number -
�//C�A _ _ / �5
(ll �1/Y��`LO Y�� a�-i 3- yov _ oo� • 6 So -o �- s�
Is ihe property used and occupied primarily (or � Assessed value oi the property as ot March 1, current year (may not
hismer residence? exceed $144,000)
Yes ❑ No
Was the applicant 65 years of age or more on December o( fhe year poes fhe combined annual adjusied gross inwme of the applicant and any
prior to the current year? individuats sharing ownership exceed $25,0007
es ❑ No ❑ Yes ❑ No
ApplicanYs date of birth (monfh, day, year) Souree of Income Amount of Income
- $ --�
I( filed by a surviving, unmarried spouse, what was the spouse's age at $
the 6me of death?
TOTAL $
Have you filed for any other deductions? It Yes, what deductlo�s?
� Yes ❑ No
Have you filed for deductions in any other count� If Yes, whaf county?
❑ Yes ❑ No
I/We certify under penalty of pery'ury that the above and foregoing information is true and correct and that the applicant was a resident I
of Indiana and owner of the a(orementioned property on March 1, 20
Signa��pl�n���� ( Signature of authorized representative (by execufed Power o)AflomeY)
.ress of applicant � Address of authorized representative
j�z�� F/ 3�o S i. 7yS
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