Age_Frohbieterf �_n•n '.: AFFIDAVIT OF PERSON� 65 YEARS OF AGE OR MORE� OU T N H YEAR
iQ REQUESTING DEDUCTION FROM ASSESSED VALUATION ,1
'+ � SUteFortnd3708(R614-0a) �UN O `i Z00%
• Prescnbed by the Depariment oi Local Gwemmant Finance
��aµ �e Mark
rtnation contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.7•35-9. �j'a-�,
INSTRUCTIONS:
To 6e filed in person or by mail wiih the CountyAuditor of the county where
the propeRy is located.
See reverse side for additional instruclion and qualifications.
Q �
FILING DAlCS�BSON COUNTY AUDITOR
1) Rea/ propeify: Dunng the 12 months 6e(ore May
11 0! the year the deduction is to be elfective.
2) Mobile homes assessed unde�l.C.6-1•1-7;
6etween January 15 and March 31 of the year
the deduction is to be effective.
owner? If No, what is his/her exad share or mteres . If owned with wmeone other than spouse,
' indicate with whom
Yes ❑ No
I( name on record is diBerent than ihat of applicant, indicate below
Name of contract seAer (applicant must have 6een buying on cnnhact at feast one (1J }reer)
Address o( contrad seller Is the property in question:
eal property ❑ Mobile home (I.C. 6•1-1-7)
T ing district Key number / Legal description Record number Page number
'L Z - - -3 -o .a
Is the property used and occupied primarily for Assessed value of the property as o( March 1, cunent year (may not
hisRier residence? exeeed $144,000)
❑ Yes ❑ No
Was the applicant 65 years of age or more on December 31 of fhe year �
�
Have you filed (or any other deductions? If Yes, whal deductions7
❑ Yes ❑ No
Have you filed tor deductions in any other wunty? If Yes, whal wunty?
❑ Yes ❑ No
I/We certiry 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 _
Address of authorized representalive
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