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� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S,w� � State Form 43708 (RS / 6-03)
Prascnhe0 by Ue Departrneni of Lofal Govemment Finance
In!ormatlon contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
�
COUNTY TOWNSHIP YEAR
File Mar1c
RUCTIONS: FILING DATES:
To be filed in person or by mail with the County Auditor of the county where 1) Real property: During the 12 months be%re May
the propeRy is located. 11 0/ tbe ea� the deduction is to be eNective
See reverse side /or additional insUuction and qualifications.
auolicant the sole leaat or
name on record is diReren�
�
ame of contract selle fano
�� � ��,7
owner? If No, what is hisRier
❑ Yes ❑ No
convact�
residence?
must
on cont2ct at least one
number I Legal description
�Yes ❑ No
tha appiicant 65 years of age or mwe on Dece ber 31 of the year
to the current year?
�Yes ❑ No
canYS date of birth (month, day, year)
/
d by a surviving, unmartied spouse, what was ihe spouse's age at
me of dea[h?
yau
Have you
any
❑Yes ❑No
or
Y •
2) Mo6ile ho s assessed undErriC: 7;
between J�uary 15 and Ma�37 N� year
the deductron is fowbe�'aAectiveJ �
`' h��DITOR
Is the property in questlon:
property ❑ Mobile home (I.C. 6-7-1-n
:tl value ot Ne propeRy as of March t, wrtent year (may not
$,«.�, `7� 3 b o
e combined annual adjusted gross income of the applicant and any
als sharing ownership exceed 525,000?
❑ Yes No
❑ 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 _
d
^ ` Address of authorized representative
��
(by executed Power o7Attomey)