Age_Greerw
AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
4 ! Stata Fwm a3708 (RS / 603) -
iM�
Prescnbed Cy the Department of Loral Govemment Finance
��ation contained in this document is CONFIDENTIAL pursuant to IC 61.1-12-9.
COUNTY TOWNSHIP YEAR
File Mark
UCTIONS: FILING DATES:
To be filed in person or by mail with the Counry Auditor of the county where 1) Real property: Dunng the 12 months befora May
the propeRy is located. 11 0/ fhe year the deduction is to be eflective.
� 2) Mobife homes assessed under I.C.6-1-1-7;
See 2verse side lor additional instiuction and qualifications. 6etween January 15 and March 31 0/ the year
the deduction is to be effective.
of applipnt (owner or
or
name on
❑ No
of conVad seller (applicant must have
�
property usac
r residence?
Was the
pnor to t
etl by a survm
tlme of death?
you
65 years of age or more on
year?
� birth (month, day, year)
�� �
ng, unmarried spouse, wha�
any other deductions?
you filed tor deductions in any other
No, what � hisRier exact share or
on conhact at least one
� '" � -� . t.—e
I with someona other than spouse, j'�
wiNwhom � �� .� i vi i
=iRSG:d
I Is the property in questlon:
❑ Real properry ❑ Mobile home (I.C. 6-7-1-�
Key number / Legal description Record number Page number
exceed
es ❑ No
December 31 of the year poes th
individu
es ❑ No
-
was lhe spouse's age at �
❑ No
of the property as of March 7, curtent year (may nof
�mbined annual adjusted gross income of the appficant and any
sharing ownership exceed 525,000?
❑ Yes ❑ No
�
❑ Yes �'fJo �
INJe 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
�nature of applicani n � � Signature of authorized representative (by executed Power o7Attomey)
o( applicant �� _ IAddress of authorized