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4 e_. 4 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
' " REQUESTING DEDUCTION FROM ASSESSED VALUATION
� SUte Fortn 43708 (R6 / G-04) �
Prescnbed by tha Depariment o/ Local Govemment Finance
�rmaUon wntained in this document is CONFIDENTWI pursuant to IC 6-1.7-72-9 and IC 6-�.7-359.
INSTRUCTIONS:
To be filed in person o� by mail with fhe County Auditor o( the county where
the property is located. •
See reverse side !o� additional instruction and qualifications.
COUNTY TOWNSHIP Y R
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File Mark
JUN 1 1 2001
FILING DATES:
1) Real prop�y��Q�nFg,tfy��,12 months 6elore May
11 of the year the deduc."lion is to 6e effective.
2) n.fd6l�stDH,Se:e�3�3'sdB�Bhifer°i.c.s-�-ta;
between January 15 and March 31 oI the year
the deduction is to be eNective.
Name of applicant ner or contract buye�) �
Is applicant le legal or equitable owner? If No, what is his/her exact share or interest? � I( owned with someone other ihan spouse,
' indicate with whom
❑ Yes ❑ No
If name on rewrd is diHerent than that of applicant, indicate below
Name of conVact seller (applicanf must have been 6uying on contract af least one (7) year)
Address ot conVact seller Is the property in queslion:
❑ Real property ❑ Mobile home (I.C. 6-7•7-7)
Taxing disirict Key number I Legal description , Record number Page number
� Go�a8o3UO �0.0�3-
Is the property used and occupied primarily for Assessed value of the property as of March t, curtent year (may not
his/har residence? exceed $744,000)
❑ Yes ❑ No
Was Ihe appliwnt 65 years of age or more on December 37 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the cunent year? individuals sharing ownership exceed 525,000?
❑ Yes ❑ No O Yes ❑ No
AppliwnYs date of birth (monfh, day, year) Source of Income Amount of Income
� $
If filed by a surviving, unmarried spouse, what was the spouse's age at $
the time of deaih�
TOTAL $
Have you filed for any other deductions? If Yes, what deductlo�s7 �
❑Yes ❑No
Have you Uled for deductions in any other county? It Yes, what countyl .
❑ Yes ❑ No �
IPNe certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property.on March 1, 20 _
Signature of applicant ISignature of authonzed representative (byezecutedPowerolAtfomey)
ress of applicant Address of authorized representafive �
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