Age_Gentry�� °."' � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
i' ':
REQUESTING DEDUCTION FROM ASSESSED VALUATION
Slaie Porm 43708 (R / 9-96)
•�";�'' Prescribed by Ne Sta;e Board ol Tax Commissioners
Information contained in Ihis document is CONFIDENTIAL pursuant to IC 6-1.1-12�9.
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the County Auditor ol the counry where the property is loca-
ted during the 12 months be%re May 77 0/ the year the deduction is to be eltective.
Deductions tor mobile homes not assessed as real propeRy must )i/e 6etween January 15 and
March 37.
See reverse side for additional instruction and qualilications.
nameon
�
(owner or contract buyei)
❑ Yes ❑ No I
than that ot applicant, indicate below
seiler (applicant must have been buying on contracr ar least one (7) year)
COUNTY TOWNSHIP VEAR
File Mark
4' '�� .i `k1?r•^f
i z
SX,G � 2000
xin �strici Key number / Legal description Record number Pag�
=po5-oo�7a-oe
Is ihe property use d occupied � arily tor Assessed value of the property as of March 7, wrrent year
hisRier residence? exceed $21,000)
❑ Yes ❑ No ❑ Yes
Was ihe applicant 65 years of age or more on December 31 of the year
❑ Yes LI'` N I
I/We certify under penalty of perjury that the above and foregoing in(ormation is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March t, 19
ature of applicant Signature of authorized representative (by executed Power ofAttorney)
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%3b�' �31
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