Age_Bracher�mry
4 `: AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cout�r TOWNSHIP ven,rt
r°-� :. ;�
'� ` REQUESTING DEDUCTION FROM ASSESSED VALUATION
> .% State Form 43708 (R6 / 4-04)
Prescribed by ihe Department ol Local Govemment Finance
� �''��""111 ile Mark
ITortnation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1�9.�
INSTRUCTIONS: FILING DATES: '
To be filed in person or by mail with the CountyAuditor of the county where 1) fi��r�ebtyZQQi�g the 12 months before May
the propeRy is located. 11 0( the year the deduction is to 6e eHective.
2) MQb�ile homes assessed underl.C.6-1-1-7;
See reverse side /or addi6onal insWction and qualifications. beti4eam.lan`��/15 and Maroh 31 of the year
GIBS�Orv�GUf�7� isLto��e�(fective.
Name of applicant (owner or contrect buyer) �
� �_�'LQ,�p�.
Is applicant the so�e legal or e vitable e(� If No, whaf is hislher exad share or interest? If owned with someone other than spouse,
� indicate wiih whom
Q Yes ❑ No
If name on record is diRerent than thal of applicant, indicate below
Name of contracl seller (applicant must have been buying on wntract at least one (i) year)
Address of conUact seller Is the property in ques6on:
❑ Real property ❑ Mobile home (I.C. 61-1-n
�g district Key number I L-gal description Record number Page number
QS-oo
Is the property used and ocwpied p imarity for Assessed vatue of the property as of March 7, current year (may not
hismer residence? exceed 3144,000)
❑Yes ❑No
Was the applicant 65 years ot age or more on December 31 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the current year? � �_� individuals sharing ovmership exceed $25,0001 � �
�'i'es ❑ No ❑ Yes LlYNo .
ApplicanPs date of birth (month, day, year)
$ �
Have you filed for any other deductions? deductlons?
❑ Yes ❑ No
Have you filed for deductions in any other county? If Yes, what county7
❑ Yes ❑ No
I/We 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 aforemenfioned property on March 1, 20 _
Signature of applicant Signature of authorized representative (6y executed Power o)AttomeyJ
.ess appli ni � . Address of authorized representative
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