Age_Hensley�1
.�+ ^'�
3__ � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
� REQUESTING DEDUCTION FROM ASSESSED VALUATION
��N ! State Fortn 43708 (RO / 70-01 �
Prescribed by the Department of Local Govemment Finance
Intormafion conlained in this dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS:
To be filed in person or by mail wifh the CounryAuditoro/the county where
the property is /ocated.
See reverse side for additional instrucfion and qualifications.
COUNTY TOWNSHIP YEAR
i�
e ark'�'' �
FILING DATES: R�:� 2() ZIJO�
1) Real prope :'Dunng tbe�12 month,s before May
11 0l the y r he deduction is to be eBective.
2J Mobile ���sessed�unde� LC:6�fP4 �7;
behveen January 15 and'Ma�cfi�31 o/the year
the deduction is to be effective.
Nameofapplica o erorco buyer �
�
Is appliwnt the s legal or equitable owner? If No, wh is his/her exact share or interest? � If ned vrith someone other lhan spouse,
indicate with whom
❑ Yes ❑ No
If name on record is diHerent than ihat of applicant, indicate below
Name of wntrad se er (applicant must have been buying on contract at least one (7) year)
�
Address of co� seller Is the property in question:
, ❑ Real pmperty ❑ Mobile home Q.C_ 6-1-1-�
�xin �strict Key number I Legal description Record number Page number
• 6 �55 ='��
Is e property used and pied primarily for Assessed value of the property as of March 1, current year (may not
hislher residence? exceed 569,000)
Yes ❑ No
Was the applicant 65 years of age or more on December 31 of fhe year poes the combined annual adjusted gross income of the applicanf and any
prior to the wrtent year? individuals sharing ownership exceed 525,000?
Yes ❑ No ❑ Yes ❑ No
Applicant's date of birth (month, day, year) Soure f I come Amount of Income
n $
If filed by a surv' spouse, what was the spouse's a9e at � $
the Ume of death?
TOTAL $
Have you filed for any other deducfions? If Yes, what deduc6ons?
❑ Yes ❑ No
Have you filed (or deductions in any oNer county? �f Yes, what county?
❑ Yes ❑ No
IIWe certify under penalty of perjury that ihe above and foregoing information is true and correct and that lhe applicant was a resi-
denl ot Indiana and owner of ihe aforementioned property on March 1, 20 _
Signature of applicant Signature ot authorized representative (by executed Power ofAttomey)
�ress of appliwnt Address of authorized representative