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�.,__ _? AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
'" REQUESTING DEDUCTION FROM ASSESSED VALUATION
�O � State Fortn 43708 (R6 / 4-06) �
Presmbed by ihe Depatlment of Lowl Gwemment Finance
�rmaUon contained in this document is CONFIDENTIAL pursuant to IC 6-1J-72-9 and IC 6-1.1-35-9.
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor o/ the county where
the pioperty is located.
See reverse side (o� additional instruction and quali(cations.
COUNTY TOWNSHIP YEAR
� ile}vlaik
FILINGDATES: SEP 1 3 POO6
1J Real property: Dunng the 12 months before May
11 0/ the year th�duFtiQn'i�to be effective.
2J Mobile homes assessed unde�.C.6-1-1-7;
between ,�fi�'r}%� f.S�aifHTlvYafc{i�1Q�! the year
the deduction is to be effective.
Name o( applicanl (owner or conVact buyer) � .
� � e � -�
Is applicant the sole legal or equitable owne(? If No, hat is his/her exad share or interesl? If ow d with someone other than spouse,
' indica with whom
❑ No
If name on record is diRerent fhan at of applicant, indicate below
Name of wntract seller (applicant must have been buying on contract atleast one (1) }rear)
Address of contraci seller Is the property in questlon:
�_/�-C�]-a0��O0� % �����7 ealproperty ❑MObilehome(/.C.6•1-7-7)
Taxing district Key number / Legal desttiption Rewrd number Page number
W ^ ���� n �V
Is �he property used and occupied primarily for Assessed value o( ihe property as of March i, current year (may not
hislher residence? exceed 5744,000)
Yes ❑ No
Was the appliwnt 65 years ot age or more on December 31 of Ihe year poes the combined annual adjusted gross income of the appiicant and any
prior to the currenl year? individuats sharing ownership exceed 525.0007
es ❑ No ❑ Yes o
Applicanfs da;e of birth (month, day, year) Source of Income Amount of Ineome
s age at $
ihe time of death?
TOTAL $
Have you filed for any other deductions? I i( Yes, what deducGons?
❑ No
Have you filed (or deductions in any other county? If Yes, whal county?
❑ Yes �
UWe 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 applicant I Signature of authorized representative (by executed Powe� ofAttomeyJ
ess of applicant Address of auNorized represeniative
� R 12 3,�i o z� • s�
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