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� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNrr TOWNSHIP renR
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S,w � State Fortn a3708 (RS / 6-03)
Prescribed by the Departrnent of Loral Govemment Finance
Inf�rtnalion contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
�RUCTIONS:
To be �led in person or by mail with the County Auditor of the county where
the property is located.
See reverse side (or additional insWction and qualifica[ions.
� aDDlicant Ne sole legal or equitable owneN I If No,
f[] Yes ❑ No
name on record is difterent ihan that of applicant, indical
coniract
seller
residence?
must
for
share orinteresi7
on contract at least one
number I Legal description
�Yes ❑ No
Was the applicant 65 years of age or more on December 31 of the year
prior ro [he curtent year?
❑ Yes ❑ No
Appiicant's date of birth (month, day, yearJ
� -
If filed by a surviving, unmarried spouse, what was ihe spouse's age at
the ume ot deaN?
you filed for any
you filed for deductions in any
0 Yes
❑ Yes
_.� � � Fihe-Mark�—��
�
FILING DA � � � �
1) Real property: Dunng Ihe 12���!qonths belore May
11 o/the year�iheNdeductidrl7l�`�o be effective.
2J Mobile homes assessed under I.C.6-1-1-7;
betwe� January 15'and.,AAarch 3.1 of ��p�e year
� ---< %
fhe de uction-is4o�6e_e8ective:v3-� �
�� GISSON �[!?i!LtiTY AUCII!'_
I with someone othar than spouse,
wiN whom
Is the property in question:
❑ Real property ❑ Mobile home (I.C. 6-7-1-�
Record number Page number
the property as of March 1, wrtent year (may not
� o�-� 00 �
ombined annual adjusted gross income ot the applicant and any
sharing ownership exceed 525,000?
❑ Yes ❑ No
�
I/We certify under penalty of perjury that the above and foregoing intormation is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned property on March t, 20 _
�
,Q Q �
/
of auNorized representative