Age_Walker' °i°a
i AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
'�n " REQUESTING DEDUCTION FROM ASSESSED VALUATION
. _
�O ,�✓'• State Fortn 43708 (R6 / 4-04)
� Prescribed by ihe Department of Lacal Govemment Finance
Information wntained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-t.t-35-�
INSTRUCTIONS: FILING DATES:
To be �led in person or 6y mail with the County Auditor oI the county where 1) Real �rt� lJ�r`�Q�° 12 months be(ore May
the properfy is located. 11 of the year the deduction is to 6e effective.
2) Mobi es a ed under 1.C.6-1-1-7;
See reverse side !or addi6onal instruction and qualifications. betw d March 31 of the year
�1��gS�1'C�� 105'�P �fi�flve.
Name of applicant (owne� or contract
Is applirant fh�sole legai or ' ble ovmer? If No, what
l
Q Yes ❑ No
I( name on record is different than that of applicant, indiwte bel�
Address of conVact seller
and occupied primariy
the appliwnt 65 years of age or more on
to the current year?
any other deductions?
you filed for deductions in any oiher
exact share or interest?
on conhact af least one (1) year)
❑Yes ❑No
December 31 0( the year
❑ Yes ❑ No
was the spouse's age at
❑ Yes ❑ No
nry1
❑Yes ONo
� someone
whom
property in queslion:
spouse,
❑ Real property ❑ Mobiie home (/.C. G7-7-�
Rewrd number Page number
Assessetl value ot the properry as
exceed 3744,000)
Does the combined annual adjustf
individuals sharing ovmership exci
IPNe certify under penalty of perjury lhat the above and foregoing information is true and correcl and lhat the applicant was a resident
of Indiana and owner of the aforementioned property on March 1, 20
applicant
�J
representalive (by executed Power olAttomeyJ