Age_Cleveland�� � a�J
dj rt'"at AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE� OWNSHIF
-1 REQUESTING DEDUCTION FROM ASSESSED VALUATIO�AY r f7ff
��� S�are Form a3708 (R i 9-96) J �9JJ
°' Prescribed by ihe State Board ol T� Commissioners
� �� `2 jFile Mark
Information contained in ihis document is CONFIDENTIAL pursuani to IC 6-1.7-72-9. �"`-'"+-JF�(J°�"+
Gi3SOt� C[; u�rv nnrnm�a �
INSTRUCTIONS FOR FILING:
To be liled in person or by mail with the Counry Auditor ol the county whe�e the property is loca-
ted during the 72 months betore May 77 ol the year the deduction is to be e!)ective.
Deductions for mobile homes not assessed as real property must lile between January 75 and
March 31.
See reverse side lor additional instruction and qualilicarions.
YEAR
Name of applicant (owner oi contracf buyer)
r _ _ _.
Is applicant the sole legal or equitable owner? If No, what is his/her exact share of interest? If owned with someone other than spouse,
indicate wiih whom
❑ Yes ❑ No
tl name on record is dittereni than that of applicani, indicate below
Name ot coniraa seller (applicant must have been buying on contract at /easr one (7) year)
Address of coniract seller
�ing districi Key number / Legal description Record number Page number
a�-� f���:::-�j-� `�•O 1 D-1=- �-
Is the property used and occupied primarily for Assessed value of the property as of March 1, current year (mayno(
hisfier residence? exceed $27,000J
❑ Yes ❑ No ❑ Yes ❑ No
Was the applicant 65 years of age or more on December 37 of the year poes the combined annuai adjusted gross income ot the applicant and an
prior to ihe current year? individuals sharing ownership exceed 520.000?
❑ Yes o
Applicant's date ot birth (month,
$
Have you filed for any other deductions? It Yes, what deductions?
❑ Yes ❑ No
Have you filed for deductions in any oiher counry? If Ves, what county?
❑Yes ❑No
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a resi-
dent of Indiana and owner of the aforementioned property on March i, 19
Signature of applicant SignaNre of authorized representative (by executed Power o7Attomey)
� �
ress of applirani Address of authorized representative �.�`
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