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„s,__, � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courm TOWNSHIP veaR
� REQUESTING DEDUCTION FROM ASSESSED VALUATION p�
> < State Fortn 43708 (R614-04)
•• Prescnbed by lhe Department of Local Govemment Finance
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.iation contained in this document is CONFIDENTIAL pursuant to IC 6-7.1-12-9 and IC 6-1.735-9.
INSTRUCTIONS: FILING DATES: �AN O 5 ZOOE
To be filed in person or by mail with the CountyAuditor of the county where
the propeRy is located.
See reverse side fo� additional instruction and qualifications.
1) Real properry: Dunng the 12 months 6efore May
11 of the year the de� s�6�e/fective.
2) Mobile homes asses e�er l.C.b��1-�1�-j �
between Januap�g§mWrf�4}H1f�t�hL�y�ar
the deduction is fo be effective.
Name of applirant (ow or contract buyer) �
a a
Is applicant the sole legal or equ' b ownef? If No, what is h' r exact share or interest? If owned with someone other than spouse,
' indicate with whom
es ❑ No
If name on rewrd is different than that of applicant, indicate below
Name of contract seller (applicant must have been buying on contrect at least one (i) year) •
Address of contract seller Is the property in question:
� 1 Real property ❑ Mobile home (I.C. 67-7-7)
Taxin district Key number I Legal d�escription Rewrd number Page number
�/�Q � . (��'" Q � 'i' �PO- —YV
Is me property used and occu ied primarily for Assessed value of the property as o( March 1, wrtent year (may not
hisRier residence? exceed 5744,000)
❑ Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year poes the wmbined annual adjusted gross inwme of the applicant and any
prior to the current year?/ `n individuals sharing ownership exceed $25,0007
�Q� 'S °�`� ❑ Yes ❑ No ❑ Yes ❑ No
AppliwnPS date of birth (month, day, year)
Have you filed for any other dedudions? If Yes, what deductions?
❑ Yes ❑ No
Have you filed for deductions in any oiher county? If Yes, what counry?
❑ Yes ❑ No
IlWe 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 appiiwnt J Signature of authorized representative (6y execufed Power olAttomey)
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ess of applicant Address of authorized representative
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