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4 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
� Siate Fwm 43708 (RS / 6-03)
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Prescribed by ihe Department of Local Govemment Fnance
�^`�rtnation contained in this dowment is CONFIDENTIAL pursuant to IC Et.1-72-9.
�RUCTIONS:
To 6e filed in person o� 6y mail with the Counry Auditor of the county where
the property is located.
See reverse side /or additional insWcfion and qualifications.
COUNTY TOWNSHIP YEAR
d ;' 'N u �+�' 7
� � � `� File Mark�%
FILINGDATES:.JUN �:` ZOO�
1) Real property: Dunng tbe 12 months belore May
11 of the year the deduction is to'be eNectiva. --
2)Mobile.homes-a ss essedunderL•`G.6�1-1-7;
between''January 15 enii A.laich'31 0/ the year
the deduction is to be eflective.
Name of applicant (owner or cont2ct buyer) •
r--- —
_i_
� . - -
Is applicant the sole lega � aquita6le owneR If N wh is hisRier exact share w interest? If owned th someone other than spouse,
indicate th whom
S ❑ No
If name on record is different than t of appliwnt, indicate below �
Name of contract seller,(applicant must have been buying on conhact at least one (1) yearJ
Address ot conVaa seller Is the property in question:
�
eal property ❑ Mobile home (I.C. 6-7-7-�
Tauing district Key number I Legal de cri ti n Record number Page number
OoG -o/� ��-eG
� _�-o_ _ - c�
e property used and occupied primarity for Assessed value of the property as of March 1, current year (may not
er residence? exceed $144,000)
❑ No
Was the applicant 65 years of age or more on December 31 ot Ne year poes the combined annual adjusted gross income of the applicant and any
prior to the curtent year? individuals sharing ownership exceed 525,0007
�s ❑ No ❑ Yes �
ApplicanPs date
the spouse's age at $
Ihe Gme of death?
, TOTAL $ � �g
Have you filed for any oiher deducUons? If Yes, what deducUons?
�es ❑ No
Have you filed for deductions in any other county? If Yes, what counry?
❑ Yes o
I/We certify under penalty of perjury that the above and foregoing infortnation is true and cortect and that the applicant was a resident
ot Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applitani �� Signature of auNorized representative (by executed Power ofAttomey�
i
A ress of applicant �� Address of auihorized representative
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