Age_Becke n•`t AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
° REQUESTING DEDUCTION FROM ASSESSED VALUATION
'� � SWte Fortn 43708 (R6! 4-04)
Prescribed by Ihe Department af Local Govemment Finance
I�rmation contained in this dxument is CONFIDENTIAL pursuanl to IC 6-1.1-12-9 and IC 6-1.1-35-9.
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where
the property is located.
See reverse side for additional instruction and qualifications.
COUNTY TOWNSHIP YEAR
File Mark
A;;;Y U 'L 2005
FILING DATES:
1) Real property: D�dj�g the� nths 6efore May
11 of the year the dei� � 6e e/%ctive.
2) Mobile hg�g�,ep�gFj� b�i'1'7;
between January 15 and March 31 oflhe year
the deducfion rs to be effective.
Name of applicant (owner or contract buyer) �
Y
Is applicant the sole legal or uita le ovmel? If No, at is hisR�er e t share or interest? If owned with someone other than spouse,
�p � indicate with whom
� � �es ❑ No
If name on rewrd is diHerent than that of appliwnt, indicate below
Name of contract seller (applicant must have 6een buying on cont2ct at least one (1J year) •
Address of conVact seller Is the property in question:
eal property ❑ Mobiie home (I.C. G7-1-�
T�g district Key number / Legal description Record number Page number
� �
Is the property used and occupied primarily for Assessed value of the property as of March 1, current year (may not
hisR�er residence? exceed 5744,000)
❑ No
Was Ne applicant 65 years of age or more on December 37 of the year poes the combined annual adjusted gross income of the applicant and any
prior to the current year? individuals sharing ownership exceed $25,0001
��s O No � C] Yes
ApplicanPs date of birth (month, day, yearJ Source of Income Amount of Ineome
� _ _ $ -SS
If filed by a surv'rving, unmartied spouse, what was the spouse's age at $
the tlme of deaih?
TOTAL $ S5
Have you filed for any other deductions7 It Yes, what deductions?
LXres ❑ No
Have you filed for deductions in any other county? If Yes, what county7
❑ Yes Ll'P�Y �
I/We certify under penalty of perjury that the above and foregoing information is true and correcl and thal the applicant was a resident
of Indiana and owner of the aforemenfioned property on March 1, 20 _
Signaturpof , plicani Signature of authorized representative (by executed Power ofAttomey)
' / ` � :
_ss of a iwnt � Address of authorized representative
Sd0 � Loevs! � ,�lt,�e , ''^r!1
�.t�y