Age_Gehl (3)-°+ 'rt �= AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
`'� REQUESTING DEDUCTION FROM ASSESSED VALUATION
�� �° State Form 43708 (R6 / 4-04)
• Presuibed by tlie Department of Lowl Govemmem Finance
�nation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o( the county where
the propeRy is located.
See reverse side for additional instruction and qualifications.
COUNTY I TOWNSHIP
FILING DAT �p
1) Real pro !ry:`D�iin�j l���f months be(ore May
11 of the year the deduction is to 6e eNective.
2) Mo6ile hb�s assg�s underl.C.6-1-1-7;
between Janua� 9� a�d March 31 of the year
theCif@�JddQ�tAR�C dfl�l74Wt
Name of applicant wner or contrdct buyerJ �
Is applicant the sole legal r equitable ovmer7 If No, what is hi er exact share or interest? I( owned with someone other than spouse,
' indicate with whom
Yes ❑ No
If name on record is difierent an that of applicant, indicate below '
Name ot contract seiler (applicant must have 6een buying on contract at least one (1) year)
Addres Is the property in question:
� � �Real property ❑ Mobile home (I.C. 61J-n
Ta�dn i Uict Key number / legal description Record number Page number
� � ��` ° � C.J"'�x�
Is fhe property used and occupied p imarily tor Assessed value of the property as o( March 1, curtent 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
$
Have you filed for any other deductions? It Yes, what deducUons?
❑ Yes ❑ No
Have you filed tor deduUions in any olher wunty? If Yes, whal county? !
❑ 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 aforementioned property on March 1, 20 _
SignaNre ot appiicant Signature of authorized representative @y execufed Power o)Attomey)
�� � � ��
ss of applicant Address of authorized represenlative
� �'t/ .i