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� � AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
'� `" REQUESTING DEDUCTION FROM ASSESSED VALUATION
�> ,��� � State Form 43708 (R6 / 5-Od) �
Presrnbed by the Depanment af Lowl Govemment Finance
,�..�ormatlon wniained in this document is CONFIDENTIAL pursuant to IC 6-1.1-12-9 and IC 6-1.735-9.
1NSTRUCTIONS:
To be �led in person or by mail with the CountyAuditor ol the county where
the p�operty is located.
See reverse side lor addilional instn�ction and quali(cations.
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FILING DATES: '�j12� ���
1J Real propertyr Dunng tha 12 mon �fore May
11 of the y��eM'��''to�YS�a��e�ffective.
2) Mo6i/e homes assessed under I.C.6-i-1-7;
between January 15 and Marti+ 31 0l the year
the deduction is to be eflective.
Name of applicant (owner or conUact buyerJ �
/ i / � / � Kl-"'�
C�
Is applicant the sole legal or equitable owner? If No, what is his/her exact share or interesl? If owned with someone other than spouse,
' indicate with whom
O Yes � No
If name on record is diBerent than that of applicanl, indicate below
Name of wnVact se0er (applicanf must have been buying on conVact af least one (7) year)
Address o( contract seller Is tha property in question:
Real property � Mobile home (I.C. 6-1-7-7)
�g disVict Key number / Legal descriptlon � Record number Page number
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Is the property used and occupied primariy for Assessed value of the property as of March 1, current year (may not
hismer residence? exceed $144,000J
❑ Yes ❑ No
Was the applicant 65 years ot age or more on December 31 of the year poes the wmbined annual adjusted gross inwme of the applicant and any
pria to the cunent yearl
$
Have you filed for any other deductions? If Yes, what deduc6ons?
❑Yes ONo
Have you filed for dedudions in any other wunty7 If Yes, what counryl
❑Yes ❑No
i/We certify under penaliy of perjury that the above and (oregoing information is true and correct and that the applicant was a resident
of Indiana and owner of the atorementioned property on March 1, 20 _
Signature ot applicant Signature of authorized representative (by executed Power olAttomeyJ
ress of applicant � Address of aulhorized representative
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