Age_Schmits..'
� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courm' TOWNSHIP vFaaa
�Y� � REQUESTING DEDUCTION FROM ASSESSED VALUATION
�� + State Fortn 43708 (R6 / 4-0a)
Prescnbed by ihe Department of Lowl Govemment Finance
��mation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.135-9. �� F� q�
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INSTRUCTIONS:
To 6e filed in person or by mail wiih the County Auditor of the county where
the propeRy is located.
FILING D�
1) Real property: Dunng the 12 months 6efore May
11 o/the year��le��io�}slo 6e effective.
2) Mobile homes assessed under 1.C.6-1-1-7;
See reverse side /or addifional instruction and qualifications. between January 15 and,�aGch 31 of fhe year
the deductio�s7oZve e`ffect�e.
i AUDITOR
Name o( applicani (owner or co act buyer) �
i� �
Is applicant the sole legal or equitable ovmer? If No, what is hisRier exact share or interest? If owned with someone other than spouse,
' indicate with whom
Yes ❑ No
I( name on record is diHerent t an Nat ot applicant, indicate below
C� � . �
Name of contract seller (applicant must bave been b'ng on contract at least one (i) year)
Address of contract seller Is lhe property in queslion:
�� � � �a (,, � �,G�J[(._/[� ❑ Real property O Mobile home (LC. 67-7-n
Taxing district Key number / Legal descripGon Record number Page number
�'�uex� Qi � Gb � oii� 9-cb
Is the property used and occupied primarily for Assessed vatue of the property as of March 1, curtent year (may not
hisRier residence? exceed 5144,000)
❑ Yes ❑ No
Was the appliwnt 65 years of age or more on December 31 of the year poes ihe combined annual adjusted gross income of the appliwnt and any
prior to the current year? individuals sharing ownership exceed $25,0007
❑ Yes ❑ No ❑ Yes ❑ No
Appliwnt's da:e of birth (
Have you filed (or any other deducfions7 If Yes, whal deductions?
H. S. Yes ❑ No
Have you filed tor deductlons in any other count�? If Yes, what counly?
❑ Yes No "
,
I/We certify under penalty of perjury that the above and foregoing information is true and correcl 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 representative (by executed Power ofAttomey)
L
'ess of applicant Address of authorized representative
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