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e•"'TMa AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
as�. q�, REQUESTING DEDUCTION FROM ASSESSED
'� VALUATION State Form 43708 (1-90) Prescribed by the
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°• State Board of Tax Commissioners
Ins ructions for filing:
To be filed in person or by mail with the County Auditor of the County where the
property is located during the 12 months before May 11 of the year the deduction
is to be effective. Deductions for mobile homes not assessed as real property
must file between January 15 and March 31. See reverse for additional instructions
and qualifications.
County
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Township� Year
SEP 2,91992
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AUDITOR
Applicant (Owner or con c buyer)
Is applicant the sole le r If no, what is his/her exact share If owned with someone other than
equitable owner? yes O no interest? spouse, indicate with whom.
If name on record is di rent than that of p licant, indicate low:
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Name of contract seller (App nt must have been buying on contra a le one (1) year.)
Address of contract seller
,�) Di ct Key Number/ _ e_ cri ti _.0 O Record No.
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Is the reai property used and cupied Assessed value of the property as of March 1, current
for his/her residence? � es ❑ no year (may not exceed $19,000).
Was the icant 65 years of age or more on ApplicanYs date of birth _ _
Dece er 31 of ihe year prior to the current year? ��
yes ❑ no If filed by a surviving, unmarried spouse, what was the
spouse's age at the time of death?
Does the combined annual adjusted gross Source of income Amount of income
income of the appli and any individuals 5 6 d•
sharing owne ip exceed $15,000? .
❑ yes ' no �
Total �
Have you filed for any other deductions? If yes, what deductions? „
Have you filed for any deductions in any other county? If yes, what county? � „ , �,
I/We certify under penalty of perjury that the above and foregoing information is true and cor�ect and that the appli-
cant was a resident of Indiana and owner of the aforementioned property on March 1, 19
��ature Authorized Representative (by executed Power of Attorney)
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Address of Applica9t �� � Address of Representative
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