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a 'i AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courm TOWNSHIP veaR
'� � ` REQUESTING DEDUCTION FROM ASSESSED VALUATION
�' State Form 43708 (R6 / 4-04)
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Prescnbed by Ne Depariment of Local Govemment Finance
�iatlon wntained in this document is CONFIDENTIAL pursuant to IC 6-7.7-12-9 and IC 6-1.1-35-9. �� �� M�
INSTRUCTIONS: FILING TE �°'
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To 6e filed in person or by mail with the County Auditor of the county where 1) Real property: Dunng the 12 months 6e%re May
the property is located. 11 0/ the yq��e �e�f��s to be ef/ective.
2) Mobile homes assessed under 1.C.6-1-1-7;
See reverse side for additional instruction and qualifications. between Jaqu_ary 15 and arch 31 of the year
the deducti6Hes4Q b� tive.
J
Name of appliwnt wne or conVact buyer) �
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Is applidnt the sole legal or equitable ovmer? If No, what is his/her exact share or interest? If owned with someone other than spouse,
�,/� ' indicale with whom
L'�es ❑ No
If name on record is ditferent than that ot appliwnt, indicate beiow
Name of convact selier (applic t must have been buying on contract at least one (1) year)
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Address of wnVact seller Is the property in queslion:
❑ Real property ❑ Mobile home (I.C. 6-1-1-7)
Ta�d d'stric ,, -. w � Key number / Legal description Record number Page number I
���'J'� 0 l I -D� d9 �( -�O
� e property used and occupied primarily for Assessed value of the property as ot March 1, current year (may not
his/her residence? exceed 3144,000)
es ❑ No
Was the appiicant 65 years of age or more on Dece ber 31 of Uie year poes the combined annual adjusted gross income of the applicant and any
prior to the cunent year? individuals sharing oxmership exceed $25,0007
❑ Yes ❑ No ❑ Yes ❑ No
AppliwnPs date of birth (month, day, yearJ
$
Have you filed (or any other deductions? I( Yes, what deductions?
❑ Yes ❑ No
Have you filed tor deduUions in any other wunry? If Yes, what wunry? �.
❑Yes ❑No
IM/e certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant was a residenl
of Indiana and owner of the aforementioned property on March 1, 20 _
ignature of appliwnt Signature of authorized represeniative (by executed Power o7Attomey)
_✓ "�ti /
�Aress of appliwnt IAddress of authorized representative I
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