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AFFIDAVIT OF PERSON, 65 YEARS OF AGE OR MORE,
REQUESTING DEDUCTION FROM ASSESSED VALUATION
State Fortn 43708 (R4 / 70-01)
Presaibed by Ihe Department of Lowl Govemment Finance
�nation confained in Nis dowment is CONFIDENTIAL pursuant to IC 6-1.1-12-9.
INSTRUCTIONS:
To be filed in person or 6y mail wifh the County Auditor o/ the county where
the property is /ocated.
See reverse side foradddional instruction and qualifications.
COUNTY TOWNSHIP YEAR
Fil
FILING DATES: MAR j S�OOZ
1) Real pro erty: During the 1 months 6efore May
11 0l fh ear the de uc " �s to eff ctive.
2) Mo6i1 e��e�l •�6- �f-7;
be n�l ' �apd�� �o the year
the deduction is to be e/%ctive.
Name of applicant (owner or conVacf buyer) '
Is applirant the sole legal o qmlable owner? No, what is hislher exact share or interest? If owned with someone other lhan spouse.
indicate with whom
es ❑ No
If name on record is difterent tha at of applicant, indiwte below
Name ot contrecl seller (applicant musf have been buying on contract af least one (1) yearJ
Address of wnVad seller Is the property in question:
eal property � Mobile home (I.C. 67-1-n
Ta�dng district Key number / Legal description wrd number Page number
Is the property used and occupied primarily for Assessed vaTue of the property as of March 1, current year (may nof
hisRier residence? exceed 569,000J
�s ❑ No
Was the applidnt 65 years of age or more on December 31 of the year poes the combined annuat adjusted gross income of ihe applicant and any
prior to ihe wrrent year? individuals sharing ownership exceed $25,000?
v�'res ❑ No ❑ Yes
AppliranPS dale of birth (month, day, year) Source ot Income Amount of Income
$ S
If fded by a surviving, unmartied spouse's age at $
the time of deathl
TOTAL $
Have you filed for any olher deducGons? If Yes, what deduc6ons?
es ❑ No
Have you filed for deductions in any olher counry? If Yes, what county?
❑ Yes
I/We certify under penalry oi perjury that the above and foregoing information is true and correct and that the applicanl was a resi-
dent of Indiana and owner of lhe aforementioned property on March 1, 20 _
Signature of applicant Signafure of authorized representative (by executed Power olAttomey)
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ess applipnt �� Address of authorized representative
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