Age_MalloryN °'n
� AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE, couNTr TOWNSHIP rEa,a
: REQUESTING DEDUCTION FROM ASSESSED VALUATION
� � ! Slate Fortn 43708 (Ra / 10-01)
•� Presrn'De0 by Ihe DepartmeN of Local Govemment Finance
�!ortnation cantained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS: FILING DATES: .JUL � 2 2��2
To be filed in person o� by mail with the County Audifor of the county where 1) Real prope � uring fhe 12 th,s be�° re ay
the property is located. �°
11 /th h d f s�b fl t'
See reverse side 1or additional instruction and qualifications.
Name of ap i�ant (owner or contrect
1
Is appiicant the sole leaal or eaurtabl�
name on
of contrad
district
No, v�hat is
❑Yes ❑No I
than �hat of applicant, indicate below
(applicant
property used and occupied primarity for
r residence?
on contiact at
�es ❑ No
s the applicant 65 years of age or more on Decem er 31 of the year
�r to ihe wrtenl year?
�'es ❑ No
tlicanYs dale of birth (month, day, year)
ed by a surviving, unmartied spouse, vfiat was ihe spouse's age at
fime of death? r
you filed for any other deductlons?
you
any
� Yes
or
one (i) year)
o eye e e uci ni� ee c� .
2) Mobile ho sesse r��d'eFf`G�5��p
behveen nJ'ar����d�L}��c�h�'31 o�the year
the deduction is to be e(fective.
spouse,
indicate with
Is the property in question:
❑ Real property ❑ Mobile home (I.C. Gf-1-�
Rewrd number Page number
Assessed value of the property as
exceed 569,000)
year
$
If Yes, what deductions?
If Yes, what county?
❑Yes �No �
I/We certify under penalty of perjury lhal the above and foregoing information is true and correct and thai the applicant was a resi-
dent of Indiana and owner of lhe aforementioned property on March 1, 20 _ � _
ature of applicant SignaNre of authorized representative (by executed Power o)Attomey)
Address of aulhorized representative