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d,•� oi AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED
`; VALUATION State Form 43708 (t-90) Prescribed by the
'' •• �� State Board of Tax Commissioners
In ,ructions for filing:
To be filed in person or by mail with the County Auditor of the County where the
property is located during the 12 months before May 11 of the year the deduction
is to be effective. Deductions for mobile homes not assessed as real property
mustfile between January 15 and March 31. See reverse for additional instructions
and qualifications. „�., _ r, r,
Applicant (Owner or
.. .�
unty Township Year
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� ile r
APR 2 3 1991
I�,rv�.aJ �• on�S
Is applicant the sole le or If no, what is his/her exact share or I If owned with someone other than
equitable owner? yes O no interest? spouse, indicate with whom. •
If name on record is different than that of applicant, indicate below:
Name of contract seller (Applicant must have been buying on contract at least one
Address of contract seller
year.�
a.
�T in istrict ey Nu ber/ g I D scr' ion Record No.
. �k• A�� . 1�-�- i� ; d�J C.,d'/2 Page No.
Is the real property used and occupied primarily Assessed value of the property as of March 1, current
for his/her residence? ❑ yes O no year (may not exceed $19,000). _
Was the a licant 65 years of age or more on
Dece er 31 of the year prior to the current year?
yes O no
Does the combined annual adjusted gross
income of the app ant and any individuals
sharing owner ip exceed $15,000?
� yes no
Have you filed for any other deductions?
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Have you filed for any deductions in any other county?
If yes, what deductions?
If yes, what county? -
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
cant was a resident of Indiana and owner of the aforementioned property on March 1, 19
Signature
ress of Applicant
Authorized Representative (by executed Power of Attorney)
Address of Representative
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