Age_Kelleyi o_. •n 4 AFFIDAVIT OF PERSON� 65 YEARS OF AGE OR MORE� COUtd7Y TOWNSHIP YEAR
` REQUESTING DEDUCTION FROM ASSESSED VALUATION
���� .�� State Form 43708 (R6 / 4-Oa) �
Prescribed by ihe Depariment of Local Govemment Finance
File Mark
�rtnation contained in this document is CONFIDENTIAL pursuani to IC 6•1.1•12-9 and IC 6-1.1-35-9.
INSTRUCTIONS:
To be filed in person or 6y mail with the County Auditor o/ the county where
the property is located.
Rco �avotta eidn (nr aiiditinnal inc)nrr�inn nnrl mulifirofinnc
FILING A�E�� �
A
1) Real prope y�ln s 6efore May
11 of the y�{ e deduction is fo be e(fecfive.
2) Mobile ho'h'f��a�se�s�e�}�ider I.C.6-1-1-7;
between Januarv 15 and March 31 of the vear
. . . ... . . .......____.. __._'__._.__'._'_" _ _
' the dedu`dio�a� � �Nective.
5�
Name of applicanl (o er or contract bu r) � OUNTY qUDITOR
�
Is applicant the sole legal or equitabie ovmer? If No, what is hisfner exad share or' erest? If owned with someone other than spouse,
' indicate with whom
es ❑ No
If name on record is diBerent than that of applicant, indicate below
Name ot wntract seller (a plicant must have been buying on contract atleast one (7) year)
`-'�
Address of conVaU seller Is the property in question:
❑ Real property ❑ Mobile home (I.C. 6•1-7-�
Taxing district Key number / Legal description Record number Page number
aco-►S au-aou-axi.c��-o
Is Ihe property used and occupied primarily (or Assessed value ot Ne property as of March 1, cunent year (may nof
hislher residence? exceed 3144,000)
es O No
Was lhe applicant 65 years ot age or more on Dece ber 31 of the year poes the wmbined annual adjusted gross inwme of lhe applicant and any (
prior to tha curtent year9 individuals sharing ovmership exceed 825,0007
es ❑ No p Yes � No
Appliwnfs date of birth (month, day, year)
$
Have you filed for any other deduMions? If Yes, what deductions?
Yes ❑ No
Have you filed for deduUions in any other county? If Yes, what wunty?
❑ Yes o
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 _
Signature of ap iwnt Signature of authorized representative (by executed Powe� ofA[tomeyJ
�y
ress of applicant Address of aulhorized representative
�i'� Sc5 i�%����'�