Age_Hynemaniq _n••4� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�` � Stata Fortn 43708 (R6 / C-O4) . �
• Prescnbed by ihe DepaAment ol Local Gwemment Finance
�rmation wntained in this document is CONFIDEN7IAL pursuani to IC 6-1.1-12•9 and IC &1.1359.
INSTRUCTIONS:
To be fifed in person or by mail with fhe County Auditor ol the county where
the property is located.
See reverse side /or addifional instruction and qualifications.
COUNTY TOWNSHIP YEAR
� . � �
File Mark
JUN 0 8 2006
FILING DATES:
1) Real propeit�r Dunng theyt2,months 6e(ore May
11 of the year the�d'educfron'is to be e8ective.
2) Mobile�iAkasr's�'ssbdRJ�i�7ef-!lC.6-1-1-7;
between January 15 and March 31 of the year
the deduction is to 6e effecfive.
Name of applicanl (owner o� contract buye�) �
� / `' � U � I
Is applicant the sole I al or equitable owner? If No, what is hislher exad share or intere � If owned with someone other than spouse,
' ndiwte with whom
O�s ❑ No
If name on rewrd is diHerent fhan that of applicant, indicate below
Name o( conlract seller (appl/cant must have been buying on wnfract at least one (1) yearJ
Address oi conVact seller Is the property in question:
eal property ❑ Mobile home (/.C. 6•7-7-7)
Taxing districl Key number / Legal description Record number Page number
� 0�9�Ob �l�•oo
Is Ihe property used and occu primarity for Assessed value of the property as of March 1, current year (may not
hisRier residence? exceed 3 f 44, 000J
es ❑ No
Was the applicant 65 years of age or more on December 31 of the year poes ihe combined annuat adjusted gross income of the applicant and any
prior to the currenf year7 individuals sharing ownership exceed 525,0007
s ❑ No O Yes o
AppliwnYs
Have you filed (or any other deduciio�s? If Yes, what deductio�s? �
s ❑ No
Have you filed for deductions in any other wunty? If Yes, what county?
❑ Yes o
INVe certify under penalty of perjury that the above and foregoing information is true and cortect and that the applicant was a resident
ot Indiana and owner of the aforementioned property on March 1, 20 _
Signature of appiicant SignaNre ot authorized representative (by executed Power olAttomey)
ess of applicant / Address of aulhorized representative _
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