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'"' °""o AFFIDAVIT OF PERSON� 65 YEARS OF AGE OR MORE� cOUH7v TOWNSHIP YEAR
'` ' RE�UESTING DEDUCTION FROM ASSESSED VALUATION
`x��' State Porm 43708 (R / 9-96)
'',a;:" •' Prescnbetl by the State Boartl ofTax Commissioners
File.Mark-
Intormation coniained in ihis documeni is CONFIDENTIAL pursuant to IC 6-1.1-12-9. ' 1 { \
To be�U �TION Sso� o b/ y ma'1 with the County Auditor ol the county where the propeRy is loca- �, ������ �� �/
ted du�ing the f2 months be%re May 11 0/ the year the deduction is ro be ellective. �'
Deductions tor mobile homes not assessed as real property must lile beM1veen January 75 and F�$ 1 i� 1999
March 31. 7 n
See reverse side lor additional instruction and qualilications. ^ / Ury'i �,�I .C.�- \
: �� `�y f�1/�-�..,%.
3me of app � nt own o contract bu er)
- '���`� SC�,
,
applicant the sole legal or equitable owner? If No, what is his/her ezact share of interest?
name on record is diNereni
ame of wntrad seller (appi
ddress of contract seiler
Is the propeny use
hisfier residence?
'Ses ❑ No �
that of applicant, indicate below
must have been buying on
�'9' / "-'
�.
at least one
❑Yes ❑No
Was the applicant 65 years of aqe or more n December 37 of the year
prior to the current year?
Es �
ApplicanYs date of birth (monfh, day, year)
�
If filed by a surviving, unmarried spouse, what was ihe spouse's age at
the time of death?
Have you filed for any other detluctions?
you filed for deduciions in any other county?
❑ Yes
■ .
_ �,� r s' o v
c�a"-'� �
� someone
whom
spouse,
A55e55etl value Ot ihe property a5 ot MarCh 1, Current year (may nof
exceed $21,000)
❑ Yes ❑ No
Does ihe combined annual adjusted gross income of the applicant antl any
individuals sharing ownership exceed 520,000? .
❑ Yes ❑ No
If Yes, wh deductions? �
��Ov� eJ f �+—
If Yes. whai county?
IlWe certify under penalty of perjury that the above and toregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March 1, 19 _
��
ress ot applicant
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