Age_Mason;__�.• � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
'� � REQUESTING DEDUCTION FROM ASSESSED VALUATION
��+ �' State Fartn 43708 (R6 / a-Oa)
Prescribed by ihe Department of Local Govemment Finance
�rtnation contained in this document is CONFIDENTIAL pursuani to IC 6-1.7-72-9 and IC 6-1.1-359.
INSTRUCTIONS:
To 6e filed in person or by mail with the Counfy Auditor of the county where
the propeRy is located.
See reverse side /or additional instruction and qualifications.
Name of appliw (owner or conVact buy rJ
�' , ��j j/
Is applicant the sole legal or equitable ovmef.�
Q Yes ❑ No
If name on rewrd is dit(erent than that of applicant,
Name of contract s �er (applicant must have been
�
Address of d seller
T_ ng district ,
and occupied primarily for
the appliwnt 65 years of age or more on
to the cuvent year?
licanCS
�
sd by a surviving, unmarried spouse, x
time of death?
Have you filed for any
Have you filed for
I( No, what is hisRier exad share or interest?
idicate below
vying on contract at leasf one (7J year) ,
COUNTY TOWNSHIP YEAR
File Mark
FILING DATES:
1) Real prope�ty: Dunng the 12 months 6efore May
f 1 of the year the deduction is to be eNective.
2) Mo6ile homes assessed under I.C.6-1-1-7;
behveen January 15 and March 31 of the year
the deduction is to be ef/ective.
��� �
�If downed with som pne other than spouse,
M��.�e ���
� ��
nN C�NTY
�+ � � ���-o��yo-�
I Is fhe property ih esf n.
❑ Real property ❑ Mobile home (I.C. G7-1-�
�—�% �� Assessed value of the property as ot March 7, current year (may not
✓ � exceed3144,000)
�s ❑ NO
37 of the year
� $
1/We certify under penalty of perjury that the above and foregoing information is true and correct and lhat the applicant was a resident
of Indiana and q,wner of the aforementioned propeRy on March 1, 20 _
1 /I
7nature appli j Signature of authorized representative (by executed Power ofAttomey)
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