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1 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
° REQUESTING DEDUCTION FROM ASSESSED VALUATION
S ,W� StateFwm43708(RS/6-03)
Pfescribed by the Department of Local Govemment Fnance
InfortnaUon contained in ihis document is CONFIDENTIAL pursuant to IC 6-1.1-72-9.
�RUCTIONS:
To 6e filed in person or 6y mail with the Counry Auditor of the county where
the property is /ocated.
See reverse side /or additional instruction and qualifications.
FILING DATESF �. � O ?003
1) Real property. Dunng the 12 months belore May
11 of the year the deducfion is to be1effective.
2) Mobile homes.assessed unde� /_C�6-1-1-7;
beAveenJanuary_15�an'd�Maich;31 o/theyear
tAe'deduction'is'to be eNective.
Name of appliwnl (owner or contract buyer)
�\
� .Q.Q t�i.o� % � - - 9
Is applicant the sole legal or equitabls owneL� ifNO'WFa ��slher exact share w interest? If owned with someone othar Nan spouse,
indicate with whom
❑ Yes ❑ No
If name on record is difrerent than that of applicant, indicate below
Name ot contract seller (applicant must have been buying on controct at least one (i) year)
Address of conVact seller Is the property in question:
LJReaI pmperty ❑ Mobile home (I.C. 6-1-1-7j
Tazin[g d�i ct Key number / Legal description Record number Page number
7�' Ca0'�= �J�� 9���
�he property used and occupied pnmariy for Assessedvatue of the property as of March 1, wrtent year (may not
ier residence? exceed 5744,000)
�s ❑No �0000
Was the appiicant 65 years of age or mwe on December 31 ot lhe year poes Ne combined annual adjusted gross income of the applicant and any
p�or to the arrent year? individuals sharing ovmership exceed 525,000?
es ❑ No ❑ Yes T� tvo
ApplicanPs
�
If filed by a su ing, unmarried spouse, what was the spouse's age at $
the Ume ot death?
TOTAL 5 �
Have you filed tor any oNer deductlons? If Yes, what deducUons?
Ca3'Yes ❑ No � �
Have you filed for deductions in any oiher county? If Yes, what counry?
❑ Yes 1l�No
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the aforementioned propeRy on March 1, 20 _
ignature of applicant Signature ot authorized representative (by ezecuted Powe� o/Attomey)
Address of applicant Address of authorized representative