Age_Corn=y ,^•n41 AFFIDAVIT OF PERSON� 65 YEARS OF AGE OR MORE� COUN7Y TOWNSHIP YE1�R
REQUESTING DEDUCTION FROM ASSESSED VALUATION
�O � SWte Fortn 43708 (R614-04) '
•• Prescribed by the Depariment of Local Gmemment Finance ��
� �J 8�y
�rmation wntained in this document is CONFIDENTIAL pursuant to IC 6-1.1-72-9 and IC 6-1.1-359.
INSTRUCTIONS: FILING DATES: �UN O 7 ZOO�
To be filed in person or by mail with the CountyAuditor of the county where
the propeRy is located.
See �everse side Ior addifional instruction and qualifications.
1) Real propeRy: Dunng the 12 months belore May
11 of the year`�'retdedur4N"ory'is to 6e eNective.
2) Mobile homes asses'sed unde� I.C.6-1-1-7;
betweea�rj�y5�a'ndMaichT�'Rolthe year
the deduction is to be effective,
Name of applicant (owner o� conVact buyer) �
V O �
Is applicant le iegal or equitable ovm . what is hislher exact share or interest. If owned with someone other Ihan spouse,
' indicate with whom
s ❑ No
It name on record is diHerent than at of applicant, indicate below
Name of conlract seller (applicant must have been buying on contract af least one (1) year)
Address of contract seller Is the property in quesiion:
. �Q � �� /. � l � � � �O eal property ❑ Mobila home (I.C. 6•1-1-7)
Taxing districi Key number / Legal description Record number Page number
� 19�� �-19-�9 ao 0
Is the property used and occupied primarity for Assessed value of fhe property as of March �, curtent year (may not
hislher residence? exceed 5744,000)
❑ No
Was the applicant 65 years ot age or more on Decemb r 31 ot fhe year poes the combined annual adjusted gross income of the applicant and any
prior to the current year? individuats sharing ownership exceed 525,0007
es ❑ No O Yes ❑ No
AppliwnPs date of birth (
(
Have you filed for any other deductions7 If Yes, what deductions?
es ❑ No
Have you filed for deductlons in any oiher counry9 If Yes, what counry?
❑ Yes o
IM/e certify under penalty of perjury that the above and foregoing information is true and correct 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 execufed Power olAttorney)
_ s ���
�1r s iwnt Address of authorized representative
�� 7 S�. 7 S 3 0� Fi �3Q.��; /.v I