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' �r,,.,^ •� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courm TOWNSHIP veo,rt
�. ` REQUESTING DEDUCTION FROM ASSESSED VALUATION
I:Y' . �.� � StataFOrtn43708(R6/C-Oej .
�u.
Prescnbed by Uie Depanment of Local Govemment Finance
Information wniained in this document is CONFIDENTIAL pursuant to IC 6-1.7-12-9 and IC 6-1.7-359.
File Mark
INSTRUCTIONS: I j �D ES:�� Y
To be filed in person or by mail with the Counry Auditor of the county where 1 R 1 12 months 6efore Ma
the p�opeRy is located. 11 0l the year the deduction is to 6e effective.
) �(�fr°Q�e� ���sed underl.C.6-1-1-7;
,�e reverse side lor addifional instruction and qualifications. 2 be(ween January 15 and Maich 31 of the year
the deduction is to 6e eflective.
`,�j6� ,lS�
I Name o( applicanl (owner�r cc'ntract buyer) A a � ^
., i.� nA „ ��.,.� rniiNTY AUDITOR �
or
name on
of contract seller
the property used and
Yes ❑ No
must have been buyrng on wntract at
i applicant 65 years of age or more on
the wnent year?
AppliwnCs date of birth
If lJed by a surriving,
the time of deaih?
you
you
day, yearJ
one
I with someone other than spouse,
wifh vfiom
Is the property in questlon:
❑ Real Droperty ❑ Mobile home (/.C. 6-i-7-n
number / Legal description Recorc
a�-ii-�s- � �.
hssessed value o( the property as
exceed 5144,000)
?s ❑ No
31 of the year
3�/v Q�-�,�Li. � ��
� —
pplicant was a resident
d Power ofAttomey)