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1 AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
° REQUESTING DEDUCTION FROM ASSESSED VALUATION
• S / State fwm 43708 (RS / 6-03)
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Prescribed �y the Department af Loral Gavemment Finance
i^tortnation wnWined in ihis document is CONFIDENTIAL pursuant to IC 6-1.7-12-9.
�RUCTIONS:
To be fifed in person or by mail with the County Auditor of the crounty where
the property is located.
See reverse side for additional instruction and quali�cations.
COUNTY TOWNSXIP YEAR
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File �3 J
FILING DATES: OCT 1% Z003
7) Real property: During the 12 months befo2 May
11 of the yreai the dedur¢ion�� ro be effective.
2) Mobile h�es assessed u�de�r I,C��;
beRVee��,5�ari'�,d�ataroh�3h�he year
the deductian is to be e8ective.
Name of applicant (owner or cont2ct buyer)
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Is auolicant Ne ole le equitable owneR If No, what i er exact share or interest? If ownad with someona other Nan spouse,
" indicate vriN whom
❑Yes ❑No
If.name on record is diftarent than ihat of applicant, indicate below
Nama of conUact seller (applicant must have been buying on contrect at least one (1) }rearJ
-/ 00C3 3 $` 3 O
Address ot conVact selier ' Is the property in question:
❑ Real pmperty ❑ Mobile home Q.C. 6-1-1-n
Taxing disirict ' Key number / Legal description Record number Page number
Q� . r--�-._�-- -�I =��.8-�-�
e property used and occupied primarily for Assessed value of tha property as of March 7, current year (may not
, er residence? exceed 5744,000)
Yes ❑ No
Was the applicant 65 years of age or more on Oecember 31 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the current year? individuals sharing ownership exceed 525,000?
Yes ❑ No ❑ Yes ❑ No
Applicant's date of birth (month, day, year) Source of Income Amount of Income
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If filed by a surviving, unmartied spouse, what was the spouse's age at $
the dme ot death?
TOTAL I5 �-,
Have you filed for any other deduUions? If Yes, what deductlons?
❑ Yes ❑ No
Have you filed for deductions in any other counq!� If Yes, what counry?
� Yes ❑ No
I/We certify under penalty of perjury that ihe above and foregoing information is true and correct and that the applicant was a resident
ot Indiana and owner of the aforementioned property on March 1, 20 _
Signature of applicant Signature of authorized represen[a5ve (by executed Power o/�lttomey)
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dress of appli t Address of authorized representative
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