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� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�O Stata Fartn 43708 (RS / 603)
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Prescribed by the Department of Loral Govemrtrent Finance
�rmatlon contained in this document is CONFIDENTIAL pursuani to IC 61.1-12-9.
COUNTY TOWNSHIP .YEAR
File Mark
� .,,
the property in question:
eai property ❑ Mobile home (I.C. 6•7-1-�
Record number Page number
:etl value of the property as of March 1, current year (may not
isiaa,000� 551OC�
he combined annual adjusted gross income of the applicant and any
uals sharing ownership exceed 525,0007
es ❑ No
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I/We certify under penalty of perjury thal the above and foregoing infortnation is true and conect and that the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _ .
gnature of appliwnt Signature of authorized representative (by ezecuted Power o/AttomeyJ
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