Age_UngethumAFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, cour+rr TOWNSHIP v�
REQUESTING DEDUCTION FROM ASSESSED VALUATION
S State Fum 43708 (R7 / SO6)
.� ,� Presmbed by ihe Departniem of Lod Govertunent Finance
File Mark
InfortnaUOn contained in this dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-t13� ����
INSTRUCTIONS: FI N T
To be filed in person o� 6y mail wiih the County Auditor of the county where 1) Real property: During the 12 months before fune
ihe property is located. 11 of �j'ear t��ction is to be effective.
2) Mob�bmes assessed under I.C.6-1-1-7;
See reverse side !or additional instruction and qualifications. betwe anuar75 �,5 and March 31 of the year
the d p�8'�e'•eRective.
ff name on
iMe owneR II No, what is
Yes ❑No
that of aPOlicant. indicate below
selier (applicant musf have been bu}�ng on
ie property used and ocW petl pnmanry m
her residence?
> ihe applicant 65 years of age w more on
r to the arrent year7
dicanPs date oi
Uie spouse's age at
❑Yes
any other county�
No
exact share w
one (7) year)
I vrith someane oNe� Nan spouse,
vrith whom
Is the property in question: -
❑ Real property � Mobile home (I.C. 6-1-1-�
Remrd number Page number
as of March i, curtent year (may not
i���
�mbined annual adjusted gross income of the applicant antl any
sharing bwnership exceed 525,000?
❑Yes ❑No
❑Yes ❑No I
IIVJe certify under penalty of perjury that the above and foregoing info•*�+�}��n is We and cortect and that the applicant was a resideni
of Indiana and owner of the aforementioned property on March 1, 20
1�\nature �of applicant SignaNre of authorized representaWe (by executed Power ofAttomey)
Jl/// r ..D l /. --.�/
applicant
30 �
;::