Age_Coplen'�'��4 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
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` State Fortn 43708 (R6 / 4-04)
� Presuibed by ihe Department of Lowl Govemment Finance
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�ation wntained in this document is CONFIDENTIAL pursuant to IC 6-7.1-12-9 and IC 6-1.7359.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o/ the county whe�e
the property is located.
See reverse side /o� additional instruction and qualifications.
COUNTY TOWNSHIP YEAR
File Mark
APR 2 4 2006
FILING DATES:
1) Real property: Dunng the ]2�--dtonths 6efore May
11 of the year tiie de�OChon is�o be e/(ective.
2) Mobile i�{g�,p36S89Sgdfhh8e'ra!�:&1-1-7;
between January 15 and March 31 0! the year
the deduclion is to be eHective.
Name of applicant (owne� o� contract buyer) -
�
Is applicant the sole legal equitable o e(? If No, what is his/her exad share or interest? If owned with someone other than spouse,
� indicate with whom
es ❑ No
If name on record is diRerent than ihat of appliwnt, indicate below
Name of contract se0er (applicanf must have 6een buying on contract af least one (i) year)
Address of contract seller Is the property in queslion:
❑ Real property ❑ Mobiie home (I.C. 6-7-7-n
Ta�dng district Key number / Legal description Rewrd number Page number
� b o - c�
I ls the property used and occupied primariiy for Assessed value of ihe property as of March 1, current year (may nof
hismer residence? exceed 5144,000)
s ❑ NO
Was the applicant 65 years of age or more on Decem r 37 of lhe year poes the wmbined annual adjusted gross income of ihe applicant and any
prior to the current year? individuals sharing ownership exceed $25,0007 �p
es � No ❑ Yes �Ao .
Applicanl's date of birth (monfh, day, year)
$ �
Have you fled for any other deducUons? If Yes, what deductions?
es ❑ No
Have you filed for deductions in any oiher wunty? If Yes, what counry? .
❑ Yes o •
IIWe 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 property on March 1, 20
Signature of applicant Signature of authorized represenfative (by executed Power o/Attomey)
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' ess ot appliwnt - Address of authorized representative
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