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! AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
4 REQUESTING DEDUCTION FROM ASSESSED VALUATION
S � State Fwm 43708 (RS / 6-03�
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Ptescnbed by the Department of Lasl Govemment Finance
In� ation contained in Ihis dowment is CONFIDENTIAL pursuant to IC 61.1-12-9.
COUNTY I TOWNSHIP I YEAR
RUCTIONS: FILING DATES: —
To be �led in person o� 6y mail with the County Auditor o/ the county where 1) Real property: D�rirfg the 12 r��as before May
the property is located. 11 0l fhe ar the deduction is [o be ehective
See reverse side tor additional insVuction and qualifications.
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2) Mobile hp' mes assessed urider I.C.6-1-1-7;
beM1Veeid`JarfAarry'i5fand;d4erol�3�/ th��year
the deduc�o��s'fo be'etTective:D17O�
Name of ap icant (owner or contract bu r)
Is applicant the sole I ai or equita6le owner? If , what is hisR�er exact share or interest? If owned with someone other than spouse,
indicate wiN whom
C�7'%es ❑ No
If name on record is difterent lhan Nat of applicant, indicate below
Name af conVact seller (applicant must have been buying on cont2ct at least one (7) yrear)
Address of conVact sel�er Is the property in question:
I1� Real property ❑ Mobile home (I.C. 6-7-1-n
— ing district Key number / Legal description Rewrd number Page number
� � �tV � � —�U� / / � �J
e property used and occupied primariry for �
�
Have you filed for any other deductions? If Yes, what deducUons?
❑ Yes �lo
Have you filed tor deductions in any other county? If Yes, what wunty�
❑ Yes C9'No
I/We certify under penalty of perjury that the above and foregoing information is true and correct and ihat the applicant was a resident
of Indiana owner of the aforementioned property on March 1, 20
Signature of pliwnt Signature of authorized representative (by executed Power olAttomeyJ
�
. aress of applicant Address of authorized represen[ative