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`� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE courm TOWNSHIP reart
'ir� �'� REQUESTING DEDUCTION FROM ASSESSED VALUAT�ION •
>� : SWte Fortn 43708 (R6 / 4-04) '
• Prescribed by the Department ol Local Govemment Finance
File Mark
�na6on wntained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9. APR 2 9 2��5
INSTRUCTIONS: FILING DATES:
To be �led in person or 6y mail with fhe County Auditor o/ the county where 1) Real piop� unng 2 months before May
the p�operty is located. 11 of the ye�r t e uc� is to be effective.
2) Mob���:��q,��yptCpf3C.6-1-1-7;
See reverse side (or addifional instruction and quali(cations. between January 15 and March 31 of ihe year
the deducfion is fo be eHective.
Name of a icant (owner or contracf buyer)
/� QJ t
Is applicant the s legal or equitable ovmer? If No, what i islher a t share or interest? if owned with someone other than spouse.
' indicate with whom
❑ Yes ❑ No
If name on record is dif(erent �han that of applicant, indicate below
Name of contract seller (applicant must have been buying on contract at least one (i) year)
Address of contract seller Is fhe property in question:
Real property ❑ Mobile home (I.C. 6-7-1-7)
Ta�dng distri Key number / Legal desaiption Record number Page number
OD� - Gt�g%�- �
Is the p perty u and oc i primarily for Assessed vaNe of Ne property as of March 1, current year (may not
hisfier esiden exceedSi44,000)
❑ Yes ❑ No
Was the applicant 65 years of age or more on December 31 o( the year poes the wmbined annual adjusted gross income of the applicant and any
prior to the current year? individuals sharing ownership exceed $25,000?
� Yes ❑ No ❑ Yes ❑ No
Appliwnt's date of birth (month, day, year) Source of Ineome Amount of Income
�� $
Ii filed by a surviving, unmarried spouse, what was the spouse's age at � $
the time of death7
TOTAL $ �
Have you filed for any other deductions? If Yes, what deduclions?
�� �Yes ❑No
Have you filed for deductions in any other county? If Yes, what counlyl
❑ Yes No
I/We certify under penalty of perjury that the above and foregoing information is true and correcl and that the applicant was.a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signature of appiicant � - Signature of authorized representative (byexecufed Powe�ofAttomeyJ
T �/
�ess of ap ca � . - Address of authorized representative
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