Age_Henson_�
.�•�a �e
� �e�.
AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING.DEDUCTION FROM ASSESSED
VALUATION State Form 43708 (1-90)__Prescribed by the
State Board.of Tax CommiSsioners' _
Instructions for filing:
To be filed in person or by mail with the County Auditor of the County where the
property is located during the 12 months before May 11 of the year the deduction
is to be effective. Deductions for mobile homes not assessed as real property
mustfile between January 15 and March 31. See reverse foradditional instructions
and aualifications.
County � . Township
�
iDEC 12 1gg5
� .1�'. �h. ,
Year
AUDITO �'�'
Applicant (
interest? spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
Name of contract seller (Applicant must have been buying on contract at least one (1) year.).
Address of contract seller
��ing District Ke�NumbedLegal Desccr�.iptiorl Record No. '
—� f �_ .�..d 0: .=S—t=0�-7 Page No.
Is the real property used and cupied primarily Assessed value of the property as of March 1, current
for his/her residence? s�7 no year (may not exceed $19,000).
Was t�plicant 65 years of age or more on ApplicanYs date of birth _ _
Dece r 31 of the year prior to the current year?
es ❑ no If filed by a surviving, unmarried spouse, what was the
spouse's age at the time of death?
Does the combined annual adjusted gross Sou�ce of income Amount of income
income of the ap licant and any individuals �.
sharing owner ip exceed $15,000?
�� yes o
Total
Have you filed for any other deductions? If yes, what deductions?
Have you filed for any deductions in any other county? If yes, what county?
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
cant was a resident of Indiana and owner of the aforementioned property on March 1, 19
Address of Representative
%� �1 P. ; N « v .Y