Age_Jenkins�Rw
�`± AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, courm� TOWNSHIP vena
,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
��i l State Fortn 43708 (R6! 4-04)
Prescnbed by Ne Department o( Local Govemment Finance
File Mark
I�rmaUon contained in this document is CONFIDENTIAL pursuant to IC 6-1.7-72-9 and IC 6-1.1-35-9. �
INSTRUCTIONS:
To be filed in pe�son or by mail with the CountyAuditor of the county where
the property is located.
FILING DAT� JL � � �
1) Real property: Du�ng the 12 months belore May
11 o/the year ti�$�d�ti�nZ,�(�be ef(ective.
2) Mobile homes assessed under I.C.6-1-1-7; ��
See reverse side fo� additional instniction and qualifications. between Januap( 15 and M^ ,�rar�h 31 ot the year
the deduclion ig�6a�(�bti6i
O`
Name of applirant ( ner o contr cf buyer)� I ��� .
C�
Is applipnt ihe sole leg or equitable owner? If No, what is hislher exact share or interest? If owned with someone other than spouse,
� indicale with whom '
' O Yes ❑ No
If name on record is difterent than that of appliwnt, indicate below '
Name of conVact seil (applicant must have been buying on conVac! at least one (1) year)
`-'�
Address of cant c seller . Is the property in quesGon:
, �al property ❑ Mobile home (I.C. 67-7-�
7'n district Key number / Legal descripUon Record number Page number
, b ( I--c�o3�'7-�
Is the property used and occupied primarity for Asseued value of the property as of March 7, wrrent year (may not
hislher residence? exceed 3744,000)
❑ Yes ❑ No
Was the applicant 65 years ot age or more on December 31 of the year poes the wmbined annual adjusted gross income of the applicant and any
prior to the current year? individuals sharing ownership exceed 525,0007
pj Yes ❑ No ❑ Yes � No _
ApplicanPs date of birth (
$ �
Have you filed for any other deductions? I( Yes, whal deductions?
O Yes
Have you filed for deducdons in any other county? If Yes, whal wunly�
❑ Yes o
I/We 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 _
Si nature of applica �� � Signature ot authorized representative (by executed Power ofAttomey)
�� .-��+
.ess of appliwnt �/ �/ � Address of authorized representalive
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