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i �_, ,°._, AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�'` � SWte Fortn d3708 (R6 / <-04j
Prescribed by Ne Department of Local Gwemment Finance
�rmation contained in this documen� is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.1-35-9.
INSTRUCTIONS:
To be filed in person or by mail with the CountyAudito� of the county where
the prope�ty is located.
See �everse side fo� addilional instruction and qualifications.
COUNTY I TOWNSHIP
File
FILING DATES: �''I
1) Real propeRy: DUrl�j t��2�hs 6efore May
11 0/ the year the deduction is to be eHective.
2J Mobile homes a �� C.6-1-1-7;
befween J,3 ux, 15 d Marf,t( 31 of the year
the deducYl���'t� �`e���c(i�DITOR
Name of applicanl (owner a contract buyer) i "
� �
Is appli n ihe sole legal or equitable ownef.� f No, what is hislher exad share or interest? If owned wiih someone other than spouse,
' indicate with whom
es ❑ No
tl name on rewrd is different than that o( applicant, indicate below
Nama of contraM seller (app/icant must have been buying on contrect atleast one (i) year)
Address o( convact seller Is the property in question:
al property ❑ Mobile home (I.C. 6-7-1-7)
Taxing disVict Key number / Legal desuiption Record number Page number
�Ob - 6o a-3o - � �
- � 6 5-00
Is the property used and occupied primarity for Assessed value of the property as of March 1, curtent year (may not
hls/her residence? exceed 5744,000)
es ❑ No
Was the applicant 65 years of age or more on Dece ber 37 0( the year poes the combined annual adjusted gross inwme ot the applicant and any
priw to fhe cunent year? individuats sharing ovmership exceed 525,0007
�Yes O No ❑ Yes t7 No
Applicanl's date of birth (month, day, year) ��I Source of Income Amount of Income
� �.
�
�he time of dea�hY
TOTAL $ �5 � �
Have you filed (or any other deductions? Ii Yes, whal deductions?
❑ Yes ❑ No
Have you filed (or deduUions in any other caunty? If Yes, what counry?
❑Yes o
IIVJe certiry 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 Signature of authorized representative (by ezecuted Powei ofAttomey)
ress o( applicant Address of authorized representative
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