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e•°`�o O AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
a � County Township Year
-. REQUESTING DEDUCTION FROM ASSESSED
VALUATION State Form 43708 (1-90) Prescribed by the �� �.,ry �i �/�
�•� �� State Board of Tax Commissioners �-��- A� /
�.4.4 �.3
� 11,
Instructions for filing: �py O 4 jcJy� File Mark
To be filed in person or by mail with the County Auditor of the County wher�"'fllie
property is located during the 12 months before May 11 of the year the duction �� /J
is to be effective. Deductions for mobile homes not assessed as re �properctyJ-�y��J�,r.-�-b�-�–�
must file between January 15 and March 31. See reverse for additional i�ion� sJ�u��TY ��u!�oR
and qualifications. °`°�V
(Owner
Is applicant the sole legal or
equitable owner? ❑ yes O no
If no, what is his/her exact share or If owned with someone other than
interest? spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
Name of contract seller (Applicant must have been buying on contract at least
Address of contract seller
Key Nu
Is-the real property used and � primarily
for his/her residence? � s O no
Was the plicant 65 years of age or more on
31 of the year prior to the current year?
� no
Does the combined annual adjusted gross
income of the applicant and any individuals
sharing ownership exceed $15,000?
❑ yes ❑ no
Have you filed for any other
Have you filed for any deductions in any other county?
' � -
� a,�'
���
y, O
Record N� ��✓/
Paae No.
Ass�alue of the property as of March 1, current
year (may not exceed $19,000).
ApplicanYs date of birth
If filed by a surviving, unmarried spouse, what was the
spouse's age at the time of death?
yes,
Total
ns?
If yes, what county?
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
cant was a resident of Indiana and owner of the aforementioned property on March 1, 19
of
47
a�7a ow�n.�tUi�c�
Authorized Representative (by executed Power of Attorney)