Age_Elpers�._R.� � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
`' REQUESTING DEDUCTION FROM ASSESSED VALUATION
S,•�. � SWte Form 43708 (R6 / 4-Oa) .
Prescnbed 6y ihe DapaAment ol Local Gwemment Finance
�ormation wntained in this document is CONFIDENTIAL pursuant lo IC 6-1.1-72•9 and IC 6-7.1-359.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o/ the county where
the property is located.
See reverse side fo� additional instruction and qualifications.
COUNTY � TOWNSHIP I YEAR
FILING DATES:
1) Rea/ propeit}�id�}in�j iQe ���nths belore May
11 of the year fhe deduction is to be eftective.
2) Mo6ile home sse er/.C.6-1-1-7;
between Jan ary 1�r n'd M�th 31 of the year
the deddtRiBAk �CtprB1TOR
Name of applicant (ownei or wntract buyer) �
�A� � -
Is applicant fhe sole lega equitable owne . If N '' _exact share o inlerest? If owned with someone other than spouse,
� indicate wifh whom
5 ❑ No
If name on record is diRerent than that of appliwnt, indicale below
Name of contract seller (applicant must have been buying on contract atleast one (1) year)
Address of contract seller Is the property in question:
❑ Real property ❑ Mobile home (I.C. 6-1-7-7)
Taxing district Key nvmber / Legal description � Record number Page number
� •
�ab--:8-= 3= �= - - - -�s
Is ihe property used and occupied primariiy for •ASSessed value o( the property as of March 1, current year (may nof
hislher residence? exceed $144,000)
❑ Yes ❑ No
Was the applicant 65 years ot age or more on December 37 0( year poes fhe combined annual adjusted grass income o( the appliwnt and ar�y
prior to the current year7 individuats sharing ovmership exceed 525,000? �/ /
es ❑ No ❑ Yes {dTJo
AppiiwnPs da;
I( filed by a surriving, unmartied spouse, what was the spouse's age al j
the tlme of death?
TOTAL 3
Have you filed for any oiher deductions? If Yes, what deductions?
O Yes O No
Have you filed for deductions in any other county? 1f Yes, what wuny?
❑Yes ❑No
IPNe 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 7, 20 _
Signat e o applicant SignaNre of authorized representative (by executed Power olAtlomeyJ
ress of applicant ' \ Address of authorized representative
�gs vJ �so S �6 �